THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


EPIDEMIC  ENCEPHALITIS 

[encephalitis  lethargica] 


$3.50 


EPIDEMIC  ENCEPHALITIS 

[encephalitis  lethargica] 


BY 

FREDERICK  TILNEY,  M.D.,  Ph.D. 

Professor  of  Neurology,  Columbia  University;  Attending  Neurologist,  the 

Presbyterian  Hospital  and  the  New  York  Neurological  Institute; 

Consulting  Neurologist,  Roosevelt  Hospital,  New  York 


AND 

HUBERT  S.  HOWE,  A.M.,  M.D. 

Instructor  in  Neurology,  Columbia  University,  Assistant  Visiting  Neurologist, 
the  Presbyterian  Hospital,  New  York 


NEW  YORK 
PAUL  B.  HOEBER 

1920 


Copyright,  1920 
By  PAUL  B.  HOEBER 


Pul^lished  June,  1920 


Prinicd  in  the  Unilcd  States  of  America 


BNoedical 


FOREWORD 

Epidemic  encephalitis  has  engaged  attention  so  exten- 
sively throughout  this  country  for  the  past  two  years 
that  its  clinical,  pathological  and  etiological  features  are 
now  matters  of  general  medical  importance.  Its  con- 
currence with  influenza  emphasizes  this  importance  and 
raises  new  questions  in  an  ali'eady  perplexing  epidemic 
problem. 

Numerous  studies  of  this  form  of  disease  have  appeared 
in  many  periodicals.  Perhaps  it  is  opportune  at  the 
present  time,  however,  to  assemble  the  results  of  clinical 
studies  upon  selected  groups  of  cases  in  the  form  of  a 
small  brochure. 

This  book  contains  observations  made  on  two  separate 
groups  of  cases  which  seem  to  cover  most  of  the  recog- 
nized clinical  forms  in  which  encephalitis  may  occur. 
The  first  group,  reported  l^y  Drs.  Frederick  Tilney  and 
Henry  Alsop  Riley,  appears  as  Part  I;  the  second,  by 
Dr.  Hubert  S.  Howe,  as  Part  II. 

The  point  of  view  relative  to  each  group  is  essentially 
similar  concerning  the  main  features  of  the  disease. 
Such  minor  discrepancies  in  detail  as  may  be  apparent 
are  dependent  upon  the  variabihty  of  the  symptom- 
complex  rather  than  upon  differences  of  interpretation. 

Epidemic  encephalitis  is  now  so  well  estabhshed  as  a 
chnical  entity  that  the  lessons  learned  from  it  shed  con- 
siderable light  upon  acute  diseases  of  the  brain  which 
formerly  occasioned  much  perplexity  in  diagnosis.  The 
groups  of  cases  comprised  in  the  following  records  illus- 
trate the  protean  nature  of  this  acute  inflammatory  re- 

V 


VI  FOREWORD 

action  in  the  tissues  of  the  central  nervous  system.  It 
is  probable  that  in  the  final  analysis  the  symptom-com- 
plex will  be  considered  as  due  to  a  general  infection  in- 
volving the  system  as  a  whole,  but  expressing  itself  most 
cogently  as  an  encephalomyelitis. 


CONTENTS 

PART  I 
CHAPTER  I 

Page 

INTRODUCTION  AND  CLASSIFICATION 3 

Nomenclature — Chief  Characteristics — Division  of  Epi- 
demic Encephalitis  into  Recognizable  Clinical  Types. 

CHAPTER  II 

LETHARGIC  TYPE 5 

Profound  Somnolence,  sometimes  unaccompanied  by  but 
often  with  Cranial  Nerve  Palsies — Extreme  Asthenia. 
Case  I — History — Neurological  Examination — Cranial 
Nerves — Fatal  Termination — Post-mortem  Report  on 
Brain.  Case  II — Temperature — Mental  Depression — 
Festination.  Case  III  —  Somnolence — ^  Rigidity  —  Dip- 
lopia— ^Laboratory  Findings — Complete  Recovery.  Case 
IV — Somnolence  with  Occasional  Low  Delirium — 
Neurological  Examination — Ptosis — Mental  Inertia. 

CHAPTER  III 

CAT.\LEPTIC  TYPE 20 

Case  V — History — Neurological  Examination — ^Labor- 
atory Tests — Fatal  Termination.  Case  VI — Connection 
with  Influenza — Neurological  Examination — Long  Dura- 
tion of  Illness. 

CHAPTER  IV 

PARALYSIS  AGITANS  TYPE 27 

Presence  of  Symptoms  of  Parkinsonian  Syndrome — Agi- 
tans  Tremor.  Case  VII — Symptomatology — Neurolog- 
ical Examination — Cranial  Nerves — Rapid  Fatal  Termi- 
nation. Case  VIII — Symptoms — Neurological  Examina- 
tion— Tremor — Death  due  to  Intercurrent  Operation. 
Case    IX — Original    Mistaken    Diagnosis — Presence    of 


Vlll  CONTENTS 

Pack 
Tremor  in  Limbs  and  Extremities — Neurological  Examina- 
tion— Recovery.  Case  X — Parkinsonian  Symptoms  with 
Tremor — Neurological  Examination — Cranial  Nerves- 
Mental  Disturbances — General  Improvement.  Case  XI 
— Loss  of  Motor  Activity — Neurological  Examination — 
Absence  of  Tremor — Cranial  Nerves.  Summary  of  Dis- 
tinctive Features  of  Five  Foregoing  Cases. 

CHAPTER  V 

POLIOENCEPHALITIC  TYPE 41 

Symptoms  Related  to  Polioencephalitis,  with  Frequent 
Paralysis  of  Oculomotor  (third)  nerve — Absence  of  Leth- 
argy. Case  XII — Symptoms,  Bilaterial  Facial  Paralysis 
— Asthenia — Neurological  Examination — Gradual  Re- 
covery. Case  XIII — Delirium — Paralysis  of  Oculo- 
motor Nerves — Asthenia — Recovery.  Characteristics  of 
this  Type — Abortive  Form  of  the  Disease— No  History 
of  Influenza. 

CHAPTER  VI 

ACUTE  ANTERIOR  POLIOMYELITIC  TYPE 45 

Case  XIV — Diagnosis  of  Infantile  Paralysis — Prolonged 
Somnolence  (six  weeks)  and  Lower  Motor  Neuron  Type 
of  Paralysis,  Indicating  Involvement  of  both  Brain  and 
Spinal  Cord. 

CHAPTER  VII 

POSTERIOR  POLIOMYELITIC  TYPE 47 

Inflammatory  Affection  of  Dorsal  Root  Ganglia.  Case 
XV — Double  Vision — Herpetic  Eruption — Lethargy — 
Zoster-like  Involvements. 

CHAPTER  VIII 

EPILEPTO-MANIACAI.  AND  ACUTE  PSYCHOTIC 

TYPES 50 

Case  XVI — Hallucinosis  and  Delusions — Maniacal  Man- 
ifestations Alternating  with  Coma — Fatal  Termination. 
Case  XVII — Bronchopneumonia  Symptoms — Apathy, 
Lethargy,  Occasional  Acute  Psychosis. 


CONTENTS  IX 

CHAPTER  IX 

Paoe 

INFANTILE  TYPE  (NEONATORUM) 54 

Manifested  when  only  a  Few  Weeks  Old.  Case  XVIII 
— Sleep  Lasting  Two  Weeks  Followed  by  Paralysis  of 
Left  Side  of  Face.  Case  XIX — Three  Weeks  of  Somnol- 
ence with  Left  Facial  Paralysis.  Case  XX — Two  Weeks 
of  Somnolence  with  Paralysis. 

CHAPTER  X 

DISCUSSION M 

Critical  Analysis  of  Symptoms  and  Course  of  the  Disease 
in  Cases  Presented — Onset — Lethargy — Cranial  Nerve 
Palsies — Temperature — Tremor — Asthenia — Restlessness 
— Catalepsj' — Spinal  Fluid.     Course  and  Duration. 

CHAPTER  XI 

PROGNOSIS  AND  DIAGNOSIS 63 

Prognosis  Varies  with  Type — Guarded  Prognosis  Ad- 
visable especially  in  Early  Stage — Still  Further  Tj'pes 
Recognizable — Differential  Diagnosis — Groups  Recog- 
nized by  Spinal  Fluid  Test — By  Pathological  Tests — By 
Chnical  Tests. 

CHAPTER  XII 

NATURE  OF  THE  DISEASE 68 

Early  Forms — Communicability — Agent  not  Differen- 
tiated— Relation  to  Acute  Anterior  Poliomj^elitis — To 
Influenza. 

CHAPTER  XIII 

TREATMENT 73 

Moderate  Isolation — Principle  of  Treatment  Sympto- 
matic— Elimination — Feeding — Lumbar  puncture — Car- 
diac Stimulants — Narcotics — Rest  ('ure  During  Conval- 
escence— Massage  for  Facial  Palsy — Galvanic  Sinusoidal 
Current. 


X  CONTENTS 

PART  II 

CHAPTER  XIV 

ETIOLOGICAL  FACTORS  AND  CLASSIFICATION.        .69 

Age — Sex — Relation  to  Influenza — To  Poliomyelitis — 
Method  of  Transmission.  Classification  of  Anatomical 
Types.  General  Outline  of  Various  Forms — Meningitic — 
Cortical — Pyramidal  System — Thalamic — Corpus  Stri- 
atum— Brain  Stem — Cerebellar — Spinal — Per  i  p  li  e  r  a  1 
Nerve — Multiple  Diffuse  Lesion. 

CHAPTER  XV 

PATHOLOGICAL  CHANGES 85 

Macroscopic — Microscopic — Mesodermogenic  and  Ecto- 
dermogenic  Tissue  Changes. 

CHAPTER  XVI 

SYMPTOMATOLOGY 92 

Constitutional  Disturbances  Followed  in  2-14  Days  by 
Somnolence  or  Other  Characteristic  Symptoms — Sensory 
Disturbances  —  Mental  Symptoms  —  Fever  —  Ocular 
Symptoms.     Blood  Examination.     Spinal  Fluid. 

PROGNOSIS -..••, 107 

CHAPTER  XVII 

CASE  REPORT  I 113 

History  and  Symptoms — Physical,  Neurological  and 
Laboratory  Examinations — Slow  Onset  (4  Months) — 
Weakness — Dizziness — Drowsiness — Ocular  and  Mental 
Changes — Rapid  Recovery. 

CHAPTER  XVIII 

CASE  REPORT  II 122 

Onset  with  Head-cold,  Headache,  Fever,  Slight  Delirium 
Followed  by  Stupor,  Rigidity  and  Double  Ptosis — Death 
on  42d  Day  from  Respiratory  Paralysis. 


•  CONTENTS  XI 

CHAPTER  XIX 

Page 

CASE  REPORT  III 129 

General  Weakness — Blurring  of  Vision — Apathy — Insom- 
nia— Complete  Recovery  in  7  Weeks. 

CHAPTER  XX 

CASE  REPORT  IV 137 

Presents  Typical  Parkinsonian  Syndrome — Also  Uncon- 
trolled Smiling — Left  Facial  Weakness — Mental  Changes 
— No  Improvement. 

CHAPTER  XXI 

CASE  REPORT  V 149 

Drowsiness — Double  Ptosis — Rigidity  of  Jaw  and 
Neck.  Death  From  Respiratory  Paralysis.  Autopsy — 
Microscopical  Examination. 

CHAPTER  XXII 

CASE  REPORT  VI 164 

Weakness — Lethargy — Involuntary  Movements  of  Head 
and  Legs — Severe  Constipation.  Partial  Recovery  after 
5  Months. 

CHAPTER  XXIII 

CASE  REPORT  VII 179 

Onset  Followed  Influenza — Temperature — Weakness — 
Difficulty  in  Speech  and  Swallowing — Ataxia  of  Lower 
Extremities — Gradual  Improvement. 

CHAPTER  XXIV 

CASE  REPORT  VIII 188 

Influenza  10  Months  Previous — Headache — Blurred 
Vision — Difficulty  with  Hearing  and  Speech — Somno- 
lence. Partial  Recovery  Leaving  Hemilateral  Paralysis 
Agitans  and  Paralysis  of  Right  Face  and  Tongue. 

CHAPTER  XXV 

CASE  REPORT  IX 199 

Onset  with  Obstipation,  Fever,  Delirium  Followed  by 
DifEoulfcy  in  Walking  and  Speech,  Symptoms  Lasting 
Nearly  2  Years. 


XU  CONTENTS 

CHAPTER  XXVI 

Page 

CASE  REPORT  X 210 

Choreo-athetoid  Movements  of  Left  Arm,  Head  and 
Left  Side  of  Face.  Gradual  Onset — Stupor^Delirium 
— Choreo-athetoid  Movements  of  Left  Arm,  and  Left 
Side  of  Face.  Left  Pto.^is.  Duration  3^  Months- 
Very  Gradual  Improvement. 

CHAPTER  XXVII 

CASE  REPORT  XI 231 

Characteristic  Stupor — Clinical  Evidence  of  Lesions  of 
Brain  Stem  and  Spinal  Cord — Duration  2  Weeks  — 
Fatal  Termination — Axitopsy. 

CHAPTER  XXVIII 

CONCLUSIONS 248 

BIBLIOGRAPHY 252 


ILLUSTRATIONS 

Page 

Oculomotor  Nucleus 10 

Hemorrhage  in  Medulla 11 

Hypoglossal  Nucleus 12 

Vascular  Infiltration 13 

Hemorrhage  in  the  Thalamus 14 

Abducens  Nucleus 14 

Thalamus.  Diffuse  Cellular  Infiltration 86 

Thalamus.  Cloudy  Swelling  of  Neurocytes 87 

Thalamus.  Acute  Cloudy  Swelling  of  Nerve  Cells. . .      88 
Thalamus.  Higher  Magnification.  Severe  Degenera- 
tive Changes  and  Neuronophagy  in  Some  of  the 

Nerve  Cells 89 

Capillary  Congestion  in  Internal  Capsule  Bordering 

on  Thalamus 90 

Internal  Capsule.  Capillary  Congestion  and  Char- 
acter of  Invading  Cells 93 

Accumulation  of  Ameboid  Glia  Cells  in  the  Internal 

Capsule 95 

Internal  Capsule.  Diffuse  Cellular  Infiltration. 97 

Internal  Capsule  Showing  Adventitial  Lymph  Space 

Infiltration 99 

Internal     Capsule,     Showing     Adventitial    Lymph 

Space  Infiltration 100 

Medulla.    Hemorrhage,    Infiltration    and    Vascidar 

Changes  in  Substantia  Reticularis  Grisea 102 

Medulla.  Localized  Cellular  Infiltration  of  Formatio 

Reticularis  Grisea 103 

Medulla.     Diffuse  Infiltration 105 

Medulla.  Acute  Cloudy  Swelling  in  the  Cells  of  the 

Nucleus  Ambiguus lOG 

Medulla.  Formatio  Reticularis  Grisea 107 

Cortical  White   Matter.   Occipital  Lobe.  Localized 

Accumulations  of  Ameboid  Neuroglia  Cells 108 

Fig.  23.  Cliromatolysis  and  Acute  Cloudy  Swelling  in  tlie 

Cells  of  the  Anterior  Horns  of  the  Spinal  Cord ...    110 
xiii 


Fig. 

1. 

Fig. 

2. 

Fig. 

3. 

Fig. 

4. 

Fig. 

5. 

Fig. 

6. 

Fig. 

7. 

Fig. 

8. 

Fig. 

9. 

Fig. 

10. 

Fig. 

11. 

Fig. 

12. 

Fig. 

13. 

Fig. 

14. 

Fig. 

15. 

Fig. 

16. 

Fig. 

17. 

Fig. 

18. 

Fig. 

19. 

Fig. 

20. 

Fig. 

21. 

Fig. 

22. 

XIV  ILLUSTRATIONS 

Page 
Fig.  24.  Blood  Vessel  Showing  Virchow-Robin  Space  Packed 

with  Lymphocytes Ill 

Fig.  25.  Case    II.  Temperature    and    Pulse    Chart    During 

Final  Week  of  Illness 127 

Fig.  26.  Case  III 131 

Fig.  27.  Case  lY.  Stiff,  Slightly  Flexed,  Statuesque  Attitude, 

with  Tendency  to  Fall  Backwards 145 

Fia.  28.  Case  IV.  Parkinsonian  Facies,  Attitude  and  Tremor 

of  Right  Hand 145 

Fig.  29.  Case  IV.  Uncontrollable  Smihng  and  Weakness  of 

Left  Side  of  Face 147 

Fig.  30.  Case  V 151 

Fig.  31.  Case  V 153 

Fig.  32.  Case  V.  Temperature  and  Pulse  Chart  During  Final 

Week  of  Illness 157 

Fig.  33.  Case  VI.  Series  of  Photographs  Showing  the  Various 

Phases  of  Movement  continually  present.  No.  1 .  .    165 

Fig.  34.  Case  VI.  No.  2 166 

Fig.  35.  Case  VI.  No.  3 167 

Fig.  36.  Case  VI.  No.  4 168 

Fig.  37.  Case  VI.  No.  5 169 

Fig.  38.  Case  VI.  Composite  Photograph  with  Five  Expo- 
sures on  One  Plate  Showing  Movement  of  Head..    170 

Fig.  39.  Case  VI.  Standing  Attitude 171 

Fig.  40.  Case  VIII.  Weakness  of  Right  Half  of  Tongue 191 

Fig.  41.  Case  VIII.  Mask-like  Face  and  Characteristic  Posi- 
tion of  Arm 192 

Fig.  42.  Case  IX.  Standing  Attitude;  Showing  Slight  Tremor 

of  Legs 204 

Fig.  43.  Case  IX.  Showing  Mask-like  Expression  of  Face .  .  .   206 
Fig.  44.  Case  IX.  Showing  Facial  Weakness  on  Attempting 

to  Smile 207 

Fig.  45.  Case  X.  A  Series  of  Photographs  Illustrating  the 
Progressive  Phases  of  Movement  and  Facial  Ex- 
pression through  which  the  Patient  is  Constantly 

Passing.  No.  1 212 

Fig.  46.  Case  X.  No.  2 212 

Fig.  47.  Case  X.  No.  3 213 

Fig.  48.  Case  X.  No.  4 213 

Fig.  49.  Case  X.  No.  5 214 


ILLUSTRATIONS  XV 

Pack 

Fig.  50.  Case  X.  No.  6 215 

Fig.  51.  Case  X.  No.  7 216 

Fig.  52.  Case  X.     No.  8 217 

Fig.  53.  Case  X.  General  Position  Usually  Assumed.     Head 

Thrown    Back   and    Inclined    to    the   Left.    Left 

Arm    Flexed   and  Left  Hand  Closed.  Permanent 

Dorsal  Flexion  of  the  Toes  on  the  Right  Side...   21S 

Fig.  54.  Case  XI.    General  Appearance.   Constant  State  of 

Lethargj'- 235 

Fig.  55.  Case    XI.  Shaded  Area — Hypaesthesia,    Hypalgesia 

Thermohypaesthcsia 236 

Chart      I.  Cataleptic  Tj-pe.     Facing  page  23. 
Chart    II.  Paralysis  Agitans  Type.  Facing  page  28. 
Chart  III.  Acute  Psj'diotic  Type.  Facing  Page  53. 


PART  I 
CLINICAL  TYPES  OF  EPIDEMIC  ENCEPHALITIS 

A  Preliminary  Consideration  of  Some  of  its 
Prominent  Clinical  and  Patholooical  Mani- 
festations. 


EPIDEMIC  ENCEPHALITIS 

CHAPTER  I 

INTRODUCTION   AND  CLASSIFICATION 

The  epidemic  appearance  of  an  unusual  disease  which 
affects  the  nervous  system  profoundly  has,  during 
the  past  year,  been  the  subject  of  much  interest  and  in- 
quiry both  in  England  and  in  this  country.  From  the  fact 
that  its  most  conspicuous  clinical  feature  is  prolonged 
somnolence  it  has  acquired,  in  the  lay  prints,  the  perhaps 
not  unjustified,  if  somewhat  confusing,  designation  of 
"Sleeping  Sickness." 

Economo^^  devised  the  term  "Encephalitis  Lethargica" 
in  describing  a  similar  epidemic  in  Vienna  during  1917; 
but  as  Kinnier  Wilson^^  has  pointed  out,  this  nomencla- 
ture is  inaccurate,  since  it  is  the  patient  who  is  lethargic 
and  not  the  encephalitis;  so  that  to  label  it  "Epi- 
demic Encephalitis"  is  less  open  to  criticism  if  not  as 
picturesque. 

The    chief    characteristics    of    the    disease    are    that: 

1.  It  tends  to  appear  in  epidemic  form. 

2.  It  produces  prolonged  somnolence  or  a  state  closelj' 
resembling  lethargy. 

3.  It  gives  rise  to  palsies  of  the  cranial  nerves. 

4.  It  causes  a  marked  asthenia. 

5.  It  is  pathologically  based  upon  an  acute  encephalitis. 
Its    pathogenesis    is   a    little    understood    and    much 

debated  question. 

3 


4  EPIDEMIC    ENCEPHAIJTIS 

From  the  very  nature  of  the  lesion,  an  inflammation 
of  the  brain,  it  might  be  predicted  that  there  would  be  a 
multiformity  in  the  cerebral  symptoms.  The  remarkable 
fact  is  that  the  clinical  picture  presents  such  distinct 
generic  definition  in  spite  of  the  specific  variations  to 
which  it  is  subject.  It  is  especially  to  these  variations, 
or  subgroups  of  the  disease,  that  attention  is  here  directed 
not  only  as  a  matter  of  classification  but  also  as  an  oppor- 
tunity to  discuss  the  significance  of  the  disease  in  some 
of  its  relations  to  certain  aspects  of  cerebral  physiology. 

Of  twenty  cases  of  epidemic  encephalitis  which  have 
come  under  the  observation  of  the  authors,  eight  fairly 
well-defined  subgroups  or  clinical  types  have  been  rec- 
ognized, as  follows: 

1.  The  lethargic  type. 

2.  The  cataleptic  type. 

3.  The  paralysis  agitans  type. 

4.  The  polioencephalitic  type. 

5.  The  anterior  poliomyelitic  type. 

6.  The  posterior  poliomyelitic  type. 

7.  The  epilepto-maniacal  type. 

8.  The  acute  psychotic  type. 

Each  subgroup  is  described  because  of  some  distinctive 
feature  in  its  development  and  course.  It  would  almost 
seem  advisable  to  include  in  this  list  another  type,  the 
recognition  of  which  depends  rather  upon  the  extremely 
early  age  of  incidence  than  upon  any  particular  clinical 
feature.  At  all  events,  the  occurrence  of  the  disease  in 
infants  during  the  first  month  of  life  is  perhaps  a  striking 
enough  character  to  justify  a  tentative  group  in  the  new- 
born, encephalitis  neonatorum. 


CHAPTER  II 


LETHARGIC    TYPE 


In  this  type  of  epidemic  encephalitis  the  predominant 
clinical  feature  is  the  lethargy  or  profound  somnolence 
which  the  patient  manifests.  This  condition  can  hardly 
be  described  as  a  coma  or  stupor,  since  it  is  possible  to 
arouse  the  patient  momentarily  out  of  the  deep  sleep 
into  which  he  has  fallen,  to  gain  his  intelHgent  coopera- 
tion for  a  brief  period  in  which  there  is  evidence  of  little 
or  no  mental  clouding,  after  which  interval  he  lapses  into 
deep  sleep  again.  In  not  a  few  such  cases  the  lethargy 
continues  for  a  number  of  da3^s,  even  until  the  patient 
dies,  without  apparent  further  involvement.  In  most 
instances,  however,  the  lethargy  is  complicated  by  the 
appearance  of  cranial  nerve  palsies,  most  commonly 
paralysis  of  the  oculomotor  group,  while  in  those  cases 
which  make  a  more  or  less  complete  recovery,  an 
extreme  asthenia  develops  early  and  is  a  persistent 
symptom. 

The  first  case  illustrative  of  the  lethargic  type  is  se- 
lected as  an  especially  good  instance  of  this  variety  of 
the  disease,  and  also  because  it  has  been  possible  to  study 
the  entire  brain  stem  in  complete  serial  sections. 

Case  I.  Mrs.  de  la  C,  married,  age  thirty-six, 
whose  previous  personal  and  family  history  had  little 
bearing  upon  her  final  illness.  Four  weeks  prior  to  the  on- 
set of  the  disease  she  suffered  from  what  had  been  re- 
garded as  an  influenza  bronchitis.  She  was  not  seriously 

5 


6  EPIDEMIC    ENCEPHALITIS 

ill  at  any  time  during  this  affection  and  made  what  ap- 
peared to  be  a  complete  and  satisfactory  recovery.  One 
morning  after  an  apparently  good  night's  rest,  she  failed 
to  rise  at  her  usual  hour,  and  in  fact,  showed  no  inclina- 
tion to  do  so.  This  at  once  attracted  the  attention  of  her 
family,  since  she  had  always  been  an  energetic  and  effi- 
cient housekeeper.  It  was  found,  however,  that  in  spite 
of  all  efforts  to  arouse  her,  she  would  fall  asleep  again 
after  opening  her  eyes  for  a  few  seconds  and  responding 
intelligently  to  questions  asked  her,  without  seeming  to 
realize  anything  except  that  she  was  very  tired  and  wanted 
to  sleep.  In  the  brief  periods  in  which  she  was  awake 
and  conversed  with  the  family  her  replies  to  questions 
indicated  that  she  was  suffering  no  pain  and  was  not  con- 
scious of  any  distress.  When  seen  by  her  physician  she 
was  still  in  the  same  deep  sleep,  breathing  regularly  and 
with  normal  heart  action.  The  temperature  taken  by 
mouth  showed  no  elevation.  This  somnolence  continued 
for  two  days  interrupted  only  by  brief  periods  during 
which  she  was  sufficiently  aroused  to  take  small  quan- 
tities of  food  and  fluid,  both  of  which  were  swallowed  in 
a  normal  manner.  Her  almost  trance-like  condition 
aroused  the  suspicion  in  her  physician's  mind  that  the 
patient  was  suffering  from  hysteria,  and  upon  this  basis 
he  sought  some  explanation  in  the  more  recent  occur- 
rences of  her  life.  It  developed  that  there  had  been  some 
slight  misunderstanding  between  the  patient  and  her 
husband,  but  upon  careful  investigation  this  proved  to 
be  nothing  more  than  many  other  similar  and  customary 
differences  which  had  occurred  in  the  past.  After  two 
more  days  of  increasing  somnolence,  the  theory  of  hys- 
teria was  finally  abandoned  and  the  patient  was  seen  by 
a  neurologist.  At  this  time  it  was  still  possible  to  arouse 
the  patient  for  an  instant  or  so,  but  immediately  she 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS       7 

would  lapse  back  into  a  profound  and  quiet  sleep.  When 
asked  to  open  her  eyes,  she  attempted  to  comply,  but  was 
unable  to  elevate  the  lids,  in  spite  of  the  fact  that  she 
clearly  understood  the  request  to  do  so.  Swallowing  had 
become  difficult  and  unless  fluids  were  carefully  given, 
would  cause  paroxysms  of  coughing  and  some  regurgi- 
tation of  the  fluid  through  the  nose.  When  requested  to 
protrude  the  tongue,  the  patient,  although  appearing 
to  understand  what  was  said,  was  unable  to  move  the 
tongue  in  any  direction.  On  several  occasions  she  at- 
tempted to  speak  but  her  voice  sounds  were  feeble,  husky 
and  indistinct.  When  her  lids  were  elevated  by  the  ex- 
aminer, there  appeared  to  be  a  slight  double  external 
strabismus  and  a  widely  dilated  pupil  which  did  not  react 
to  light  upon  either  side.  The  pulse  and  respiration  were 
normal  and  the  temperature  by  rectum  was  101  degrees. 

The  remainder  of  her  neurological  examination  showed 
that  all  of  the  deep  reflexes  were  present,  including  the 
jaw,  pectoral,  biceps,  triceps,  radius,  ulnar,  wrist,  patellar 
and  Achilles,  and  equal  on  the  two  sides.  Of  the  super- 
ficial reflexes,  the  upper  and  lower  lateral  abdominals 
were  present  and  equal,  right  and  left.  There  was  no 
Babinski,  Chaddock,  Oppenheim,  Gordon  or  Schaefer. 

No  abnormal  involuntary  movements,  such  as  tremors, 
twitchings  or  spasms,  were  observed  in  any  part  of  the 
body,  nor  were  they  observed  or  reported  at  any  time 
during  the  disease. 

No  estimate  could  be  made  of  the  muscle  strength, 
although  the  patient  was  able  to  and  did  move  all  four 
extremities  and  occasionally  turned  from  one  side  to  the 
other.  The  electrical  reactions  were  not  taken.  Myotatic 
irritability  was  normal. 

It  was  impossible  to  obtain  anj''  satisfactory  estimate 
of  general  somesthetic  sensibility,  because  of  lack  of 


8  EPIDEMIC    ENCEPHALITIS 

cooperation  on  the  part  of  the  patient.  It  did  appear, 
however,  that  she  had  perception,  especially  of  the  pin- 
point and  tubes  containing  hot  water.  She  showed  evi- 
dent displeasure  when  stimulated  in  this  way  or  by  over 
extension  of  the  fingers  and  toes. 

Concerning  the  cranial  nerves,  no  conclusion  could 
be  drawn  with  reference  to  the  special  senses,  although 
she  seemed  to  see  when  the  eyelids  were  opened  and 
understand  what  was  said  to  her.  The  eyegrounds 
were  normal;  the  pupils  were  widely  dilated  but  did 
not  react  to  light,  either  directly  or  consensually.  The 
drooping  of  both  lids  was  evidently  due  to  a  definite 
ptosis,  and  the  existence  of  a  slight  degree  of  double 
external  strabismus  has  already  been  noted.  There  was 
no  nystagmus  or  other  involuntary  eye  movements. 
In  the  later  stages  of  the  disease  the  jaw  muscles  seemed 
to  have  become  paralyzed,  as  the  lower  jaw  dropped  and 
the  mouth  gaped  widely.  There  was  distinct  weakness 
of  both  sides  of  the  face,  while  the  difficulty  in  deglutition 
and  phonation,  together  with  a  paralysis  of  the  tongue, 
have  already  been  mentioned. 

At  the  end  of  the  fourth  day  of  her  illness  she  was  trans- 
ferred to  the  hospital  for  further  investigation.  Her 
temperature  had  risen  to  103°  by  rectum,  her  respiration 
was  shallow,  and  her  heart  action  weak.  The  systolic 
blood  pressure  registered  100  mm.  Hg. 

Examinations  of  the  blood  and  spinal  fluid  were  en- 
tirely negative;  the  spinal  fluid  showed  no  increase  in 
cells  and  no  globulin,  and  was  negative  to  the  Wasser- 
mann  test. 

Deglutition  became  increasingly  difficult,  so  that  it  was 
necessary  to  feed  and  stimulate  by  rectum.  During  her 
second  day  in  the  hospital,  respiration  grew  progressively 
more  shallow  and  seemetl  to  ])e  interfered  with  by  some 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS       9 

obstruction  in  the  upper  respiratory  passages.  It  ap- 
peared advisable  to  make  a  laryngoscopic  examination 
in  order  if  possible  to  determine  the  point  of  obstruction. 
This  examination  revealed  a  bilateral  total  paralysis 
of  the  vocal  cords.  Several  hours  after  the  laryngoscopic 
examination,  respiration  ceased  and  finally  after  a  few 
gasping  attempts  to  breathe,  the  patient  died  of  respii-a- 
tory  paralysis. 

POST-MORTEM    REPORT    ON    THE   BRAIN 

The  Meninges.  The  dura  mater  covering  the  convexity 
of  the  brain  and  also  upon  the  base  was  normal  in  its 
appearance.  The  pia  mater,  however,  especially  that 
covering  the  basal  surface,  showed  a  considerable  degree 
of  injection,  while  upon  the  convexit}'  nothing  considered 
pathological  was  noted. 

Surfaces.  All  surfaces  of  the  brain  were  normal  in 
appearance,  there  being  no  evidence  of  hemorrhage, 
softening  or  atrophy. 

Macrotomic  Sections.  Sections  of  the  brain  in  the 
gross  showed  nothing  pathological  in  the  cerebral  or 
cerebellar  hemispheres.  The  entire  brain  stem  was 
intensely  injected  and  had  a  pinkish  appearance  sugges- 
tive of  recent  inflammatory  reaction.  This  was  particu- 
larly true  of  the  medulla  oblongata,  the  midbrain  and 
the  thalamus. 

Microtomic  Sections.  Upon  microscopic  examination 
the  pia  mater  covering  the  medulla  oblongata  showed 
considerable  injection  and  there  was  a  moderate  degree 
of  round  cell  infiltration,  not,  however,  comparable  to 
the  condition  seen  in  lethal  cases  of  acute  anterior  polio- 
myelitis. Two  of  the  cranial  nerve  nuclei,  the  nucleus 
hypoglossi  and  nucleus  ambiguus,  were  specially  inves- 
tigated;  both   of   these  areas   showed   distincl    ('clluhu' 


10  EPIDEMIC    ENCEPHALITIS 

changes  and  nearly  all  of  the  cells  in  both  nuclei  appeared 
to  be  pathological.  These  alterations  varied  from  a  mod- 
erate degree  of  cloudy  swelling  with  eccentric  nucleus 
and  obscurations  of  the  Nissl  bodies  to  a  fairly  ad- 
vanced chromatolysis  in  which  the  more  central  layers 
of  tigroid  bodies  had  disappeared.  A  slight  degree  of 
neuronophagia  was  manifest,    especially  in   the   hypo- 


FiG.   1. — Oculomotor  Nucleus. 

glossal  nucleus.  Ameboid  glia  cells  could  be  observed 
collected  around  many  of  the  motor  cells  of  the  nucleus 
which  were  in  a  more  advanced  stage  of  degenerative 
change. 

The  blood  vessels  in  the  medulla  oblongata  presented 
an  interesting  picture;  both  veins  and  arteries  were  much 
engorged,  •  but  the  hyperemia  was  more  pronounced 
upon   the  venous  than  on  the  arterial  side.  Numerous 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS       11 

small  hemorrhagic  areas  were  observed,  especially  around 
the  smaller  veins,  and  a  fairly  well  defined  cellular  infiltra- 
tion was  found  in  the  adventitial  lymph  spaces  which 
contained  accumulations  of  leucocytes  and  plasma  cells. 
A  slight  degree  of  gliosis  was  discernible  in  and  about 
the  nucleus  of  the  hypoglossal  and  vagus  nerves. 

Pons   Varolii.     This  portion  of  the  brain  stem  also 
showed  a  slight  degree  of  infiltration  in  the  pia  mater. 


Fk;.   2. — Heiuorrlui^i    m   AkUalla. 


The  nucleus  abducentis  was  especially  studied,  and 
here,  as  in  the  case  of  the  medulla,  the  large  motor 
cells  showed  evidence  of  acute  change,  varying  from 
intense  cloudy  swelling  to  a  moderate  degree  of  chro- 
matolysis.  In  a  few  instances,  the  cell  bodies  showed 
vacuolization.  The  vascular  picture  was  similar  to  that 
observed  in  the  medulla  and  was  characterized  by  numer- 


12 


EPIDEMIC    ENCEPHALITIS 


ous  small  hemorrhages  apparently  in  relation  to  the 
veins,  all  of  which  were  intensely  injected.  The  teg- 
mental portion  of  the  pons  presented  a  slight  degree  of 
gliosis,  but  this  could  not  be  made  out  with  certainty  in 
the  basal  portion. 

Midbrain.     More  pronounced,  perhaps,  in  this  region 
than  in  any  other  portion  of  the  brain  stem  were  the 


•    * 


r*.'".  '.■    * 


*A    -^ 


^■^*v 


-— ^■'> 


=j^ftt: 


Fig.  3.— Hypoglossal  Nucleus. 


changes  already  described.  Not  only  did  the  motor  cells 
in  the  third  nerve  nucleus  and  the  cells  in  the  red  nucleus 
show  such  changes  as  cloudy  swelling  and  chromatolysis 
with  a  moderate  degree  of  neuronophagia  and  vacuoliza- 
tion, but  the  hemorrhagic  areas  were  more  numerous, 
and  in  many  places  the  vessels  showed  thrombosis  with  a 
tendency  to  necrotic  change  in  the  adjacent  tissues. 
This  was  particularly  true  of  the  region  of  the  midbrain 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS       13 

immediatel}'  about  the  substantia  nigra.  Similar  hemor- 
rhagic and  throm])otic  changes  were  observed  in  the 
thalamus,  hj-pothalamus  and  corpus  striatum. 

A  summar}^  of  the  pathological  alterations  observed 
in  this  case  justified  the  diagnosis  of  acute  polioen- 
cephalitis. The  nuclear  changes  in  the  medulla  explained 
the  paralj^sis  of  the  tongue  and  the  final  failure  of  cardiac 


Fig.  4. — Vascular  Infiltration. 


and  respiratory  action.  In  the  same  manner  the  altera- 
tions in  the  midbrain  about  the  nucleus  oculomotorius 
furnished  the  cause  for  the  oculomotor  palsy,  while 
there  is  some  ground  for  the  belief  that  the  changes  in 
the  thalamus  and  about  the  aqueduct  of  Sylvius  may  \>e 
held  responsible  for  the  prolonged  and  deep  somnolence. 
The  pathological  changes  in  this  case  are  shown  in 
Figs.  1-6. 


14  EPIDEMIC    ENCEPHALITIS 


W::'r:-*y^f^'^^^j^^^ 


?»,V  ■■■'•-.  -       '  ■■•-■■■'        ,    ''iS 


Fig.  5. — Hemorrhage  in  the  Thalamus. 


Fig.  6. — Abducens  Nucleus. 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS       15 

Case  II.  The  second  case  of  the  lethargic  type  of  the 
disease  is  that  of  a  physician  forty-three  years  of  age 
who  suffered  from  influenza  in  November  of  1918.  After 
recovery  from  this  infection,  he  was  busily  engaged  in 
practice  until  March  2,  1919.  Much  of  his  time  was 
given  to  caring  for  patients  suffering  from  influenza 
during  the  severe  epidemic  of  this  disease  which  pre- 
vailed in  New  York  during  the  winter.  On  March  2,  1919, 
he  developed  a  temperature  of  104°  which  continued 
for  one  day,  and  varied  for  the  next  three  weeks  between 
100°  and  102°.  During  the  first  part  of  this  period  he 
was  restless  and  unable  to  sleep  and  then  he  began  to 
yawn  and  become  very  drowsy,  sleeping  most  of  the 
time;  he  would  even  fall  asleep  when  conversing  with  his 
friends  or  physician.  His  expression  became  glassy  and 
fixed.  He  could  be  aroused  to  take  nourishment  for  a 
few  moments  and  although  he  seemed  oriented  and  in 
complete  contact  with  his  environment,  his  entire  atti- 
tude at  these  times  was  one  of  indifference  and  apathy. 
He  remained  in  bed  for  three  weeks  until  the  fever  dis- 
appeared and  following  this  was  confined  to  the  house 
for  another  week.  Mentally  he  was  very  much  depressed, 
but  in  addition  to  a  marked  degree  of  salivation,  showed 
little  in  consequence  of  his  recent  illness.  Upon  advice, 
he  took  a  trip  to  the  mountains  which  seemed  to  do  him 
little  good;  the  depression  and  salivation  still  remained 
and  the  tendency  to  yawn  returned.  He  noticed  an 
oily  secretion  from  his  forehead,  and  his  skin  would 
show  a  red  tache  on  even  the  slightest  stimulation.  There 
was  an  unnatural  flush  over  each  malar  prominence  and 
his  face  had  a  glassy  and  fixed  expression.  Upon  return- 
ing to  practice  he  noticed  that  he  was  troubled  with 
much  nervous  unrest,  a  feeling  of  disquiet  in  his  legs. 
This  made  it  necessary  for  him  to  move  his  feet  about 
constantly  whenever  he  sat  down.  This  sense  of  disquiet 


16  EPIDEMIC    ENCEPHALITIS 

was  further  augmented  by  the  development  of  a  pecuhar 
contraction  of  the  muscles  of  the  big  toe  on  the  right 
foot,  which  occurred  spasmodically  many  times  a  day 
whether  he  was  walking  or  at  rest.  Ijatterly  he  has  com- 
plained of  a  slight  tendency  towards  festination,  so  that 
while  the  case  may  be  considered  as  representative  of  the 
lethargic  type,  it  seems  to  tend  in  its  late  consequences 
towards  some  of  the  features  of  the  Parkinsonian  syn- 
drome, especially  the  wax-mask,  the  disquietude  in  the 
legs,  and  the  tendency  towards  propulsion. 

Case  III.  P.  E.,  Presbyterian  Hospital,  No.  40,374. 
Male,  fifty-two  years  of  age,  driver  by  occupation.  On 
January  1,  1919,  the  patient  developed  a  fever,  became 
markedly  irrational  and  complained  of  severe,  constant 
headache.  His  history  showed  no  previous  illness,  either 
recent  or  remote.  He  had  not  suffered  from  influenza. 
After  a  period  of  marked  restlessness  and  insomnia 
lasting  three  days  after  admission  into  the  hospital,  he 
gradually  became  more  and  more  somnolent  and  re- 
mained in  a  stage  of  lethargy  for  three  weeks.  During 
this  time  he  could  be  aroused  and  for  a  moment  or  two 
would  respond  to  questions  and  follow  simple  instruc- 
tions. He  took  his  food  well  and  would  even  sit  up  in 
bed  if  instructed  to  do  so.  Immediately  after  being 
aroused,  however,  he  would  lapse  back  into  a  somnolent 
condition,  in  which  he  would  remain  almost  without  a 
movement  of  his  limbs  for  a  number  of  hours.  Both  arms 
and  legs  were  held  in  a  semiflexed  position  most  of  the 
time,  but  it  was  possible  to  extend  them  without  much 
force,  the  muscles  seeming  to  be  in  a  slight  degree  of 
spasticity.  All  the  deep  reflexes  were  active  and  equal 
on  the  two  sides.  There  was  no  clonus  and  no  Babinski 
or  any  other  pathological  reflex  observed.  On  January  14, 
1919,  the  right  pupil  was  larger  than  the  left  and  was  fixed 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS       17 

to  light  stimulation.  There  was  also  a  right  divergent  stra- 
bismus but  the  fundoscopie  examination  showed  nothing 
abnormal  in  either  eye. 

Upon  testing  the  vision,  it  was  found  that  there  was  a 
diplopia  on  looking  both  to  the  right  and  to  the  left. 
This  was  considered  indicative  of  a  partial  paralysis  of 
the  third  nerve'on  the  right  side. 

The    following    laboratory    records    are    significant: 

January  2,  1919.  Spinal  fluid,  5  c.c.  withdrawn, 
slightly  tinged  with  blood.  There  was  no  increase  of 
pressure.  The  fluid  contained  23  lymphocytes  and  5 
polymorphonuclear  cells.  No  organism  was  detected  in 
the  smear;  the  culture  of  the  fluid  was  negative,  as 
was  also  the  Wassermann  reaction. 

Blood  culture  on  the  same  date  was  sterile;  the  stools 
showed  no  blood,  bacillus  typhosis  or  bacillus  dysenteriae. 
The  blood  Wassermann  test  was  negative  and  the  blood 
count  showed  white  blood  cells  12,700;  polymorpho- 
nuclear cells  83  per  cent. 

Januarj^  10,  1919.  Blood  count  normal.  X-ray  of  the 
skull  negative. 

January  11,  1919.  Spinal  fluid,  15  c.c.  of  clear  fluid 
obtained  under  no  increase  of  pressure.  Cell  count  showed 
12  l3'mphocytes  and  1  polymorphonuclear  cell.  Globulin 
was  negative,  culture  was  sterile,  Wassermann  test 
negative. 

A  guinea  pig  injected  with  the  fluid  obtained  from  the 
lumbar  puncture  remained  normal. 

Subsequent  Wassermann  tests  upon  the  blood  and 
spinal  fluid,  as  well  as  blood  counts  and  chemical  inves- 
tigation  of   the   blood,    revealed   nothing   pathological. 

The  patient  remained  in  this  stuporous  condition  until 
the  1st  of  February,  1919,  but  at  this  time  was  fairly 
rational  when  questioned,  although  he  occasionally 
attempted  to  get  out  of  bed. 


18  EPIDEMIC    ENCEPHALITIS 

On  February  3d  the  patient  became  more  acute  men- 
tally and  was  quite  rational.  His  somnolence  had  almost 
entirely  disappeared;  he  sat  up  in  bed  and  ate  with 
apparent  enjoyment.  During  the  following  week  he  gave 
the  impression  of  a  man  suffering  from  some  mental 
impairment  without  fever  or  other  indication  of  acute 
illness.  He  had  so  far  recovered  by  February  14,  1919, 
that  it  seemed  advisable  to  discharge  him  from  the  hospi- 
tal. Ultimately  he  made  a  complete  recovery. 

Case  IV.  J.  B.,  age  fifty-nine  years;  a  butcher.  In  the 
fall  of  1918,  the  patient  suffered  from  a  rather  severe 
attack  of  influenza  from  which  he  made  a  fair  recovery. 
In  the  early  part  of  December,  however,  he  suddenly 
became  ill  again  while  carrying  on  his  day's  work.  He 
complained  of  pain  in  the  head  and  great  fatigue  which 
made  it  impossible  for  him  to  remain  at  his  business.  He 
came  home  and  went  to  bed.  In  a  short  time  he  fell  into 
a  deep  sleep  and  with  the  exception  of  an  occasional  low 
muttering  delirium  remained  in  this  condition  for  the 
following  four  weeks.  His  temperature  at  the  onset  was 
102.5°,  at  which  level  it  remained  with  very  few  and  slight 
exacerbations  during  the  remainder  of  his  illness.  At  the 
end  of  two  weeks,  his  continued  lethargy  alarmed  his 
family  and  several  consultations  were  requested. 

At  this  time,  neurological  examination  showed  that 
all  of  the  reflexes  were  normal  although  slightly  more 
active  in  the  lower  extremities  than  in  the  arms.  They 
were  equal  upon  the  two  sides  and  no  pathological  re- 
flexes were  observed.  The  tone  of  the  muscles  throughout 
the  body  was  slightly  increased,  but  there  was  no  stiffness 
of  the  neck.  The  patient  remained  immobile  in  one  po- 
sition for  hours  at  a  time;  his  breathing  was  normal  and 
regular;  his  pulse  and  blood  pressure  good.  The  sensory 
examination  was  rendered  impossible  because  of  lack 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS       10 

of  sustained  cooperation  on  the  part  of  the  patient.  He 
could  be  aroused  from  his  lethargy  sufficiently  to  answer 
a  question  intelligently  and  then  would  lapse  into  sleep 
again  or  perhaps  into  a  low  muttering  delirium. 

The  cranial  nerves  showed  a  slight  degree  of  ptosis 
in  both  ej'es;  both  pupils  were  widely  dilated  and  reacted 
but  sluggishly  to  light,  with  a  slight  external  strabismus 
of  the  left  eye.  The  blood  and  spinal  fluid  were  negative 
to  all  laboratory  tests. 

At  the  end  of  four  weeks,  he  began  to  emerge  from  his 
lethargy  and  manifest  interest  in  his  surroundings.  He 
has  not,  however,  within  the  past  four  months,  recovered 
sufficiently  to  return  to  his  business.  In  fact  his  mind 
seems  to  be  blank  and  he  sits,  most  of  the  time,  in  an 
apathetic  and  indifferent  attitude,  considerably  disor- 
iented and  without  initiative.  His  oculomotor  palsies 
have    entirely  disappeared. 

This  case  is  illustrative  of  the  lethargic  type  of  the 
disease  in  which  the  cerebral  cortex  appears  to  have 
suffered  severe  injury,  as  evidenced  by  the  slow  psychic 
improvement  in  the  patient. 

The  characteristic  clinical  features  in  this  lethargic 
group  of  cases  is  the  pronounced  lethargy  which  was 
common  to  them  all,  together  with  an  elevation  of  tem- 
perature. Three  of  the  four  patients  had  previously  suf- 
fered from  influenza  within  a  relatively  short  time  of  the 
onset  of  the  encephalitis.  In  three  of  the  ca.ses,  cranial 
nerve  involvement  causing  oculomotor  and  bulbar  palsies 
occurred.  Only  one  of  the  cases  terminated  fatally  and 
that  after  a  rapid  course  of  six  days'  duration.  Of  the 
patients  who  recovered,  one  showed  no  ill  effects  of  the 
disease,  one  had  a  prolonged  asthenia,  and  the  third  is 
giving  some  evidence  of  a  tendency'  in  the  direction  of  a 
Parkinsonian  syndrome. 


CHAPTER  III 


CATALEPTIC    TYPE 


The  two  cases  of  this  group .  present  a  striking  sim- 
ilarity. Both  were  young  girls,  one  eleven  years  of  age, 
the  other  sixteen  years  old. 

Case  V.  R.  Z.,  female,  sixteen  years,  operative.  The 
patient  was  previously  a  healthy,  robust  girl  who,  upon 
returning  from  work  December  9,  1918,  complained  of 
a  severe  pain  in  the  index  finger  of  the  right  hand  which 
came  on  during  the  afternoon.  Later  in  the  evening  the 
pain  spread  to  her  right  arm,  where  it  persisted  for  several 
hours  only  to  disappear  as  suddenly  as  it  had  come,  and 
leaving  behind  it  a  slight  paralysis.  At  this  time  she  sud- 
denly became  irrational  in  her  actions.  For  a  short  time 
she  was  quite  violent,  even  requiring  restraint  and  seda- 
tive treatment.  Her  family  believed  she  had  ''gone  in- 
sane." Subsequently  she  became  quieter  and  fell  into 
a  deep  sleep.  Her  temperature  showed  a  slight  elevation 
of  102°  with  a  corresponding  quickening  of  pulse  and 
respiration.  She  continued  to  sleep  the  following  day 
and  never  from  that  time  throughout  the  remainder  of 
her  illness,  which  lasted  eight  weeks,  did  she  again  open 
her  eyes.  For  some  days  she  lay  in  this  lethargic  condi- 
tion, able  to  move  her  body  from  side  to  side  and  having 
some  voluntary  control  of  her  muscles.  At  the  end  of  the 
first  week  of  her  illness,  she  mainfested  a  general  rigidity 
in  her  entire  body  which,  however,  was  peculiar  in  the 
fact  that  the  limbs  could  be  easily  moved  from  one  posi- 

20 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS      21 

tion  into  another.  There  was  no  stiffness  of  the  neck  or 
other  evidence  of  meningeal  involvement. 

Although  seeming  to  be  in  deep  sleep,  the  patient  gave 
evidence  of  hearing  and  understanding  all  that  was  said 
to  her  when  aroused.  She  was  unable  to  make  any  ade- 
quate response  in  reply  to  questions  or  directions.  If 
asked  to  protrude  her  tongue  she  would  make  a  feeble 
effort  to  do  so.  When  told  to  flex  the  forearm  upon  the 
arm,  she  made  evident  attempts  in  this  direction  but 
seemed  unable  to  carry  out  any  voluntary  act.  Both  eye- 
lids remained  closed  and  all  her  own  efforts  to  elevate 
them  were  unavailing. 

Neurological  examination  at  this  time  showed  the 
patient  lying  supine  in  bed,  eyes  and  mouth  closed, 
forearms  slightly  flexed  on  arms,  the  latter  being  adduc- 
ted,  fingers  partially  flexed,  legs  flexed  on  thighs,  the 
thighs  slightly  flexed  upon  the  pelvis.  This  attitude  gave 
her  the  appearance  of  "an  eflftgy  on  tomb"  as  Hall'^  has 
described  this  appearance. 

She  made  no  movements;  her  deep  reflexes  were  pres- 
ent and  active  on  the  two  sides  but  there  was  no  apparent 
pathological  change  in  them. 

The  superficial  reflexes  were  present  and  active  on  the 
two  sides.  There  was  no  Babinski  or  any  modification 
of  this  reflex.  The  muscle  tone  was  markedly  increased, 
showing  a  pronounced,  inflexible  rigidity.  The  muscle 
tissue  itself  was  firm  and  tense  but  showed  no  disposition 
toward  cramping. 

The  patient  was  unable  to  cooperate,  hence  all  sensory 
tests  were  omitted.  There  was  no  response  to  tests  for  the 
sense  of  smell,  sight  or  hearing,  and  for  this  reason  it  is 
impossible  to  form  judgment  concerning  the  special 
sensory  status.  The  drooping  of  both  upper  lids  already 
referretl  to  was  due  in  part,  at  least,  to  an  oculomotor 


22  EPIDEMIC    ENCEPHALITIS 

ptosis,  but  the  impression  was  also  conveyed  that  there 
was  a  certain  increased  rigidity  in  the  orbicularis 
palpebrarum  muscles  which  tended  to  hold  the  eyelids 
closed.  The  eyegrounds  were  normal.  Both  pupils  were 
widely  dilated  and  failed  to  react  to  light.  There  was 
slight  external  strabismus  of  the  left  eye. 

The  masticatory  muscles  held  the  jaws  partially 
closed.  There  was  no  facial  palsy,  but  the  facial  muscles 
seemed  stiff  and  fixed,  giving  the  patient  an  unchanging 
expression.  The  winking  reflex  was  absent. 

The  glosso-pharyngeal,  vagus  and  spinal  accessory 
nerves  gave  no  evidence  of  pathological  involvement, 
although  at  times  the  patient  had  some  difficulty  in 
swallowing. 

In  general  appearance  the  tongue  was  normal  and 
there  seemed  to  be  no  hypoglossal  involvement.  In  so  far 
as  might  be  judged  from  the  limited  cooperation  on  the 
part  of  the  patient,  the  mental  status  was  normal. 
When  aroused,  she  heard  and  understood  what  she 
heard,  and  on  several  occasions  showed  that  she  was 
keenly  alive  to  the  purport  of  conversation  carried  on 
about  her.  This  was  particularly  evidenced  when  the 
remark  was  inadvertently  made  in  her  hearing  that  she 
was  very  ill  and  would  probably  not  recover.  Immediately 
tears  began  to  stream  down  her  cheeks,  a  reaction  which 
could  not  be  regarded  as  purely  coincidental. 

Her  family  history  was  negative  except  for  epilepsy 
in  an  older  sister  and  a  partial  hemiplegia  in  her  father 
which  has  already  cleared  up. 

The  neurological  examination  showed  that  there  was 
no  true  paralysis,  since  the  patient  could  make  faint 
indications  of  movements  in  all  parts,  her  efforts  being 
very  slow  and  of  limited  excursion.  She  was  unable  to 
raise  her  head  from  the  pillow  and  seemed  to  have  no 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS       23 

power  in  the  back  muscles.  When  any  movement  was 
attempted,  a  coarse  tremor  developed,  which  had  a 
moderate  intensity  and  began  in  the  extremities  whence 
it  spread  to  the  rest  of  the  musculature.  Repeated 
examinations  of  the  reflexes  failed  to  disclose  anything 
that  was  considered  pathological  in  this  regard  and  the 
apparent  paralysis  was  considered  as  due  to  the  increased 
muscle  tone  rather  than  to  any  direct  pyramidal  tract 
involvement. 

Of  the  cranial  nerves,  the  oculomotor  group,  including 
the  third,  fourth  and  sixth  nerves,  showed  a  right  ptosis 
and  the  right  pupil  somewhat  smaller  than  the  left. 

The  trigeminus  was  apparently  normal  in  both  its 
sensory  and  motor  divisions. 

Laboratory  Tests.  The  blood  and  spinal  fluid  were 
investigated  several  times.  In  each  instance  the  blood 
proved  negative,  both  in  its  count  and  general  mor- 
phology. The  Wassermann  was  negative,  as  was  also 
the  blood  culture.  The  spinal  fluid  was  clear  and  showed 
no  increase  in  pressure.  It  contained  three  lymphocytes, 
no  globulin  and  the  Wassermann  reaction  was  negative. 
At  no  time  did  the  urine  show  any  pathological  changes. 

The  patient's  mental  condition  remained  unchanged. 
Gradually  her  stupor  became  more  profound  until  it 
was  impossible  to  arouse  her.  This  change  was  attended 
by  a  gradual  tendency  to  increased  temperature  accom- 
panied by  an  elevation  of  the  pulse  which  fluctuated 
between  120  and  130  for  some  days  before  death.  The 
temperature  is  shown  in  Chart  I.  After  an  illness  of  forty- 
seven  days  the  patient  passed  into  a  terminal  coma  and 
died.  No  autopsy  was  obtained. 

Case  VI.  J.  B.,  age  eleven,  school  girl.  This  girl  had 
always  been  a  healthy  and  bright  child  until  December, 


24  EPIDEMIC    ENCEPHALITIS 

1918,  when  she  suffered  from  a  severe  attack  of  influenza. 
At  the  same  time  her  mother  and  two  other  sisters  had 
this  disease.  The  mother  and  one  of  the  sisters  died  of  it, 
but  the  patient  made  a  complete  and  rapid  recovery. 
She  returned  to  boarding  school  in  the  early  part  of 
January.  On  January  30,  1919,  she  was  seized  with  what 
was  considered  a  nervous  chill,  followed  by  a  rise  of 
temperature,  sleeplessness  and  a  coarse,  choreiform  type 
of  twitching  which  manifested  itself  in  all  the  muscles  of 
the  body.  Three  days  later  she  became  stuporous  and 
passed  into  what  was  considered  to  be  a  coma.  Upon 
admittance  to  the  hospital,  her  position  in  bed  was 
described  as  that  of  "an  image,"  for  she  did  not  move  her 
limbs;  her  eyes  remained  closed  and  it  seemed  impossible 
for  her  to  express  her  wishes  by  any  sign  whatsoever. 
Although  in  this  seeming  deep  lethargy  it  was  apparent 
to  those  about  her  that  she  understood  most  of  what 
was  transpiring,  for  when  instructed  to  squeeze  the 
doctor's  hand  when  she  meant  to  answer  "yes,"  she 
would  on  several  occasions  make  feeble  pressure  in  this 
way. 

The  neurological  examination  showed  a  patient,  lying 
in  bed  upon  her  back,  eyes  closed  and  cheeks  flushed, 
breathing  quietly,  with  arms,  legs  and  the  rest  of  her 
body  held  rigidly  in  a  fixed  position.  The  muscular  status 
showed  a  marked  hypertonus  which  made  passive  flexion 
and  extension  quite  difficult.  If  placed  in  a  given  position, 
the  arm  or  leg  would  remain  as  placed  without  any 
attempt  on  the  part  of  the  patient  to  change  it.  There  was 
a  slight  carpoptosis  with  moderate  flexion  of  all  fingers 
of  both  hands,  as  well  as  a  pedoptosis  with  a  tendency 
for  the  toes  to  be  held  in  plantar  flexion. 

The  reflexes,  however,  were  all  normally  active  and 
equal  on  the  two  sides.  The  threshold  of  both  patellar 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS       25 

reflexes  was  twelve  ounces,  which  may  be  regarded  as 
up  to  normal  standard.  There  was  no  clonus  at  the 
ankle  or  patella,  neither  was  there  a  Babinski  nor  any 
confirmatory  sign  of  the  same. 

The  conclusion  drawn  from  the  reflex  status  of  the 
patient  was  that,  although  she  was  markedly  hypertonic 
in  her  muscles,  this  was  not  due  to  a  pyramidal  tract 
lesion,  but  should  be  regarded  as  a  defect  in  the  extra- 
pyramidal system. 

When  passively  elevated,  both  arms  would  show  a 
coarse  oscillation  or  tremor  and  the  same  was  true  of 
the  lower  extremities.  Upon  passively  opening  the  mouth, 
a  coarse  tremor  was  noted  in  the  tongue.  There  were  no 
abnormal,  involuntary  acts  reported  or  observed  and  no 
abnormal    associated    movements    could    be    elicited. 

Tests  for  somesthetic  sensibility  were  unavailing,  since 
the   patient   could   not   cooperate   in   the   examination. 

The  cranial  nerves  accessible  to  approach,  showed  a 
bilateral  slight  degree  of  ptosis  and  some  rigidity  in  the 
orbicularis  palpebrarum  muscle.  The  third,  fourth 
and  sixth  nerves  could  not  be  properly  tested,  as  the 
patient  seemed  unable  to  move  her  eyes  in  any  direction. 
A  slight  degree  of  external  strabismus  was  noted  in  the 
left  eye.  Both  pupils  were  widely  dilated  and  reacted 
but  sluggishly  to  light.  The  muscles  of  the  lower  jaw 
manifested  a  certain  degree  of  tension  but  presented  no 
paralysis.  The  right  side  of  the  face  seemed  somewhat 
flatter  than  the  left.  Deglutition  was  difficult  and  phona- 
tion  impossible.  The  patient  could  not  protrude  her 
tongue  or  move  it  in  any  direction.  There  was  no  stiffness 
of  the  neck  muscles,  such  as  occurs  in  meningitis,  but 
there  appeared  to  be  no  power  to  move  the  head  in  any 
direction. 

Examination  of  the  blood  and  spinal  fluid  was  negative 


26  EPIDEMIC    ENCEPHALITIS 

on  repeated  tests.  The  blood  count  was  normal  and  the 
blood  culture  sterile.  Spinal  fluid  was  withdrawn  under 
a  slight  increase  of  tension  and  contained  seven  lympho- 
cytes, no  globulin  and  gave  a  negative  Wassermann 
reaction.  On  several  occasions,  the  urine  showed  a  slight 
amount  of  pus  but  this  promptly  cleared  up  on  proper 
treatment.  In  other  respects,  the  urinalysis  showed 
nothing  pathological. 

The  patient  has  remained  in  this  rigid,  lethargic  condi- 
tion for  three  months.  During  this  period  the  tempera- 
ture averaged  102°.  Once  it  became  subnormal,  and  on 
the  thirteenth  day  of  the  disease  it  suddenly  rose  to  106°, 
on  the  twenty-second  and  twenty-third  days  respectively, 
to  105°  and  104.5°,  and  on  the  thirtieth  day,  to  107.1°. 
Each  elevation  was  followed  by  a  sharp  fall  in  the  curve 
toward  the  normal  line.  The  respiration  and  pulse  did  not 
tend  to  vary  pan  po.ssw  with  the  temperature;  particularly 
was  this  true  of  the  pulse,  which  showed  a  marked 
variability  throughout  the  entire  course  of  the  disease. 

The  child  is  still  alive  and  said  to  be  improving 
slightly.  She  seems  to  have  regained  some  power 
of  expression  and  is  able  to  smile  faintly  or  indicate 
that  she  understands  the  questions  addressed  to  her  by 
gentle  pressure  of  her  hand. 

These  two  cases  are  presented  as  typical  of  the  catalep- 
tic variety  of  the  disease.  One  of  them  had  previously 
suffered  from  influenza,  while  in  the  other  no  such  history 
is  obtainable.  They  are  so  strikingly  alike  in  their 
principal  clinical  features  as  to  justify  the  recognition 
of  the  cataleptic  type  of  epidemic  encephalitis. 


CHAPTER  IV 


PARALYSIS    AGITANS  TYPE 


To  this  subgroup  belong  a  number  of  cases  charac- 
terized by  the  development  of  several  of  the  more 
important    sj'mptoms    of   the    Parkinsonian    s3'ndrome. 

Case  VII.  The  patient,  Mr.  A.  A.,  showed  his  first 
symptoms  on  January  21,  1919.  At  that  time  he  com- 
plained of  some  headache,  chillv  sensations,  and  a  nasal 
discharge.  He  felt  ill  but  denied  being  nervous  or  de- 
pressed. His  face  and  body  were  covered  with  perspira- 
tion at  frequent  intervals.  His  temperature  was  100.2°. 
He  had  a  few  mucous  rales  in  his  lungs.  On  one  examina- 
tion his  deep  reflexes  were  exaggerated,  and  there  was 
some  muscular  rigidity  which  had  not  been  recognized  by 
the  patient.  The  diagnosis  of  influenza  was  made,  and 
the  patient  received  the  influenza  vaccine,  remaining 
in  bed  until  February  3d.  At  this  time  a  lumbar  puncture 
was  made,  38  c.c.  of  fluid  being  withdrawn  under  greatlj-- 
increased  pressure.  The  Wassermann  test  of  the  fluid 
was  negative,  as  was  also  the  examination  for  tubercle 
bacilli.  There  were  six  cells  in  the  fluid  and  the  Noguchi 
test  was  negative;  the  sugar  reduction  was  normal. 
On  February  3d  the  patient  became  drowsy,  arousing  at 
times  and  occasionallj'  getting  out  of  bed.  It  was  noticed 
that  his  extremities  were  stiff  and  trembling,  especially 
on  the  right  side,  and  the  facial  expression  was  fixed  while 
the  eyelids  were  kept  closed.  He  gave  the  impression 
of  great  lassitude  and  lack  of  interest  in  his  surroundings. 

27 


28  EPIDEMIC    ENCEPHALITIS 

Especially  during  the  night  there  was  a  great  deal  of 
restlessness,  which  was  not  allayed  by  bromides  given 
in  considerable  quantities.  During  the  first  two  weeks  in 
February,  the  patient  at  times  was  out  of  bed  and  saw 
a  few  friends,  but  he  seemed  incapable  of  any  sustained 
interest.  The  stiffness  of  the  right  arm  and  hand  increased 
materially.  The  lassitude  continued  and  on  several 
occasions  there  was  retention  of  urine.  This  condition  of 
affairs  continued  until  February  21st,  when  the  patient 
evidenced  less  and  less  interest  in  his  surroundings  and 
the  restlessness  increased  at  night  to  a  low  muttering 
delirium.  During  the  latter  part  of  February,  the  patient 
became  much  quieter,  sleeping  soundly  most  of  the  time 
but  talking  and  muttering  while  asleep.  Profuse  sweating 
continued  to  appear  over  the  head  and  limbs,  while  the 
tremor  of  the  upper  and  lower  extremities  on  the  right 
side  became  more  pronounced.  On  February  28th  the 
patient  lapsed  into  a  state  of  unconsciousness  with  in- 
continence of  urine.  The  pulse  became  much  weaker  and 
the  respiration  shallow  and  hurried.  On  March  1st  he 
passed  into  coma  and  died  on  March  2d. 

The  temperature  was,  in  general,  low,  varying  from 
99°  to  100.4°  with  occasional  elevations  to  102°  and  103°, 
until  February  23d,  when  it  began  gradually  to  ascend 
and  continued  to  do  so  progressively  to  the  end,  the  final 
temperature  being  106.2°.  The  pulse  varied  between  98 
and  110  until  February  23d,  when  it  also  ascended  uAtil 
February  27th,  then  becoming  so  variable  in  force  that 
an  accurate  count  could  not  be  made.  The  respiratory 
rate  remained  constantly  around  24  until  the  24th  of 
February,  when  it  began  to  increase  rapidly.  A  record  of 
the  pulse,  temperature  and  respiration  is  shown  in  Chart 
II.  A  distinct  cerebral  tache  developed  after  the  fourth 
week  of  the  patient's  illness  and  during  the  fifth  and  sixth 


;r5 

7^/ 

1;^/^ 

s- 

?^ 

liP.  M. 

A.  M. 

P.M. 

A.M. 

P.  M. 

A.M. 

F 

'  s- 

U 

t 

^ 

/^ 

"/ 

^ 

/; 

9 

^ 

/? 

-^ 

^ 

/ 

^ 

V 

It 

^ 

: 

'- 

'- 

: 

1 

E 

E 

z 

: 

-: 

I 

I 

E 

: 

\ 

E 

\ 

'- 

: 

: 

\ 

i 

'- 

: 

: 

E 

r 

I 

: 

: 

: 

\ 

)    : 

^ 

E 

E 

^ 

: 

: 

: 

: 

''^ 

: 

\ 

E 

: 

^    [ 

^ 

^ 

; 

': 

: 

E 

z 

t 

: 

E 

t 

E 

i    - 

= 

:" 

i 

: 

\ 

i 

z 

j 

\ 

^ 

j 

: 

: 

: 

L." 

:' 

;^ 

^Y 

A 

\ 

\ 

^ 

• 

^ 

^ 

•s 

z 

^r 

1 

i 

i- 

z 

: 

■s. 

> 

:*- 

.^/ 

/: 

z 

\ 

y 

^ 

:   \ 

i 

: 

^ 

'^ 

\-, 

I 

= 

: 

E 

.X 
•r, 

,^ 

t 

-•.^ 

y' 

^ 

i- 

<: 

V- 

V'-^.. 

»: 

= 

:.. 

-f- 

: 

~i' 

\;.* 

i 

\' 

^-. 

: 

: 

: 

I 

z 

- 

- 

- 

- 

- 

. 

1    : 

: 

: 

I 

! 

E 

E 

E 

E 

: 

E 

E 

: 

CHART  II.     PARALYSIS  ACITANS  TV'PE 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS      29 

weeks  there  was  a  marked  rash  over  the  abdomen.  The 
entire  duration  of  the  disease  was  forty  days.  Several 
repeated  examinations  of  the  blood  and  spinal  fluid 
failed  to  reveal  anything  pathological. 

The  neurological  examination  of  this  patient  made  in 
the  third  week  of  his  disease  showed  a  man  of  middle  age, 
lying  supine  in  bed  with  eyes  closed  and  responding 
indifferently  to  questions.  His  face  had  a  definite  wax- 
mask  expression  and  in  the  right  arm  and  leg  there  was  a 
tremor  which  was  continuous  during  rest,  fairly  large  in 
its  amplitude  and  relatively  slow,  resembling  in  all 
respects  the  tremor  of  paralysis  agitans  and  having  the 
further  characteristic  feature  in  the  fact  that  it  dis- 
appeared when  the  patient  moved  arm  or  leg.  All  of  the 
normal  automatic  association  movements  of  the  face 
and  eye,  of  eye  muscles  and  neck  muscles,  of  the  intra- 
segmental  movements  of  the  arm  and  the  intersegmental 
movements  of  the  arm  and  leg  were  suppressed.  It  was 
possible  to  arouse  him  sufficiently  to  make  tests  of  his 
gait  and  station.  While  he  was  rising  from  the  lied  the 
complete  suppression  of  the  normal  automatic  associated 
movements,  especially  upon  the  right  side,  was  observed. 
In  standing  he  had  a  typical  Parkinsonian  attitude  and 
his  gait  presented  a  marked  festination.  When  ques- 
tioned, he  complained  of  a  feeling  that  made  him  fear 
that  he  might  pitch  forward  when  walking  or  standing 
and  he  vouchsafed  the  information  that  he  felt  that  he 
could  run  better  than  he  could  walk.  His  whole  attitude 
and  appearance  were  unmistakably  those  of  a  Parkin- 
sonian syndrome,  more  pronounced  upon  the  right  side 
of  the  body.  On  returning  to  bed,  he  immediately  lapsed 
into  a  somnolent  state  from  which  he  could  be  readily 
aroused  sufficiently  to  cooperate  with  intelligence.  The 
reflexes  of  both  upper  and  lower  extremities  were  present 


30  EPIDEMIC    ENCEPHALITIS 

and  active,  being  slightly  more  active  upon  the  right 
than  the  left  side.  There  was  no  Babinski  or  other  patho- 
logical reflex  observed  at  any  time  during  the  course 
of  his  disease.  The  abdominal  reflexes  were  present  as 
were  also  the  ciliospinals  on  both  sides.  The  muscle 
tone  in  the  right  arm  and  leg  was  distinctly  increased  as 
compared  to  that  upon  the  left  side.  Beside  the  tremor 
at  rest,  there  were  no  other  irregular,  involuntary  acts 
recorded. 

The  tests  for  somesthetic  sensibility,  in  so  far  as  the 
patient  was  able  to  cooperate,  showed  no  departure  from 
the  normal,  all  qualities  and  modes  of  sensibility  being 
intact. 

Cranial  Nerves.  The  patient  was  able  to  recognize 
several  different  aromatics  in  either  nostril.  His  vision 
was  20/20  in  each  eye  without  correction;  the  perimetric 
fields  were  impossible  of  definition  on  account  of  lack 
of  cooperation;  the  pupillary  reactions  and  the  fundi  were 
normal;  a  slight  degree  of  nystagmus  was  present  at 
times;  there  was  no  strabismus  and  no  ptosis. 

With  the  exceptions  mentioned,  the  third,  fourth  and 
sixth  cranial  nerves  were  normal.  The  trigeminus  nerve 
showed  no  disturbance  in  its  motor  or  sensory  divisions. 

In  the  facial  nerve,  no  definite  paralysis  was  observed, 
although  attention  has  already  been  called  to  the  im- 
mobility of  the  face,  giving  rise  to  a  typical  wax-mask 
appearance. 

The  ninth,  tenth,  eleventh  and  twelfth  nerves  were 
all  normal.  There  was,  however,  some  distinct  monotony 
in  the  voice  such  as  is  usual  in  cases  of  paralysis 
agitans. 

This  case  of  epidemic  encephalitis  has  its  chief  interest 
perhaps  in  the  fact  that  it  presented  the  paralysis  agitans 
type,  rapidly  running  a  fatal  course. 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS      31 

Case  VIII.  Mrs.  W.  B.,  forty-nine  years  of  age,  an 
active  and  robust  woman  who,  in  October,  1918,  suf- 
fered from  a  severe  attack  of  influenza  and  pneumonia 
particularly  affecting  the  right  lung.  This  condition 
kept  her  in  bed  for  several  weeks,  and  her  convalescence 
was  slow,  so  that  she  was  not  in  a  normal  condition 
again  until  the  beginning  of  December,  1918.  For 
several  weeks  she  went  about  as  usual  seeming  to  enjoy 
good  health;  but  about  the  middle  of  December  she 
was  stricken  again  with  an  acute  attack  giving  rise  to 
fever,  headache  and  general  malaise.  The  exact  nature 
of  this  disorder  was  not  at  the  time  clearly  understood. 
Her  temperature  did  not  at  any  time  exceed  103°,  but 
continued  for  several  weeks.  Even  after  the  temperature 
had  ceased,  however,  she  did  not  seem  to  regain  her 
health;  she  suffered  from  a  marked  asthenia,  not  merely 
of  physical  strength  but  in  initiative  as  well.  Several 
days  after  the  fever  had  left  her  she  awakened  one  night 
to  find  herself  in  a  profuse  perspiration  and  her  right 
arm  shaking  somewhat  violently;  and  this  tremor  in  the 
right  arm  and  hand  continued  without  cessation  or  much 
modification  until  the  time  of  her  death.  She  was  unable 
to  sleep  during  the  remainder  of  the  night,  and  upon 
arising  in  the  morning  noticed  that  a  similar  tremor  was 
present  in  the  right  leg  and  foot.  She  was  conscious  that 
all  her  movements,  particularly  on  the  right  side,  had 
become  annoyingly  and  perceptibly  slower  and  that 
everything  she  did  was,  in  her  own  words,  ''greatly 
slowed  down."  At  the  end  of  a  week,  her  whole  appear- 
ance and  attitude  had  changed;  the  tremor  was  not  the 
only  feature  of  her  trouble  which  annoyed  her;  for  she 
felt  a  stiffening  of  the  muscles  in  her  arm  and  leg,  to- 
gether with  a  great  sense  of  disquietude  throughout  her 
entire  body.  When  she  attempted  to  walk,  she  found  that 


32  EPIDfeMIC    ENCEPHALITIS 

her  gait  was  shuffling  and  slow.  She  herself  made  the 
observation  that  her  speech  had  a  mournful  monotony 
about  it  for  which  she  could  not  account. 

Upon  neurological  examination  at  this  time,  she  pre- 
sented a  typical  Parkinsonian  attitude  in  standing  as 
well  as  lying  down.  There  was  a  tremor  at  rest  in  the 
right  upper  and  lower  extremities  with  marked  hyper- 
tension in  all  of  the  muscles  of  the  body.  All  automatic 
associated  movements  in  the  face  and  eye  muscles,  in 
the  neck  and  arm  muscles,  in  the  arms  and  legs,  were 
either  abolished  or  distinctl}^  decreased  in  their  activity. 
The  gait  was  shuffling,  with  some  festination  and  a 
subjective  sense  of  procursion.  The  patient  stated  that 
she  felt  she  could  run  better  than  she  could  walk.  One 
very  striking  feature  of  the  case  was  the  marked  sense 
of  disquiet  and  a  desire  to  move  the  limbs  from  place 
to  place  but  finding  no  position  in  which  they  were 
quite  comfortable.  Every  position  assumed  very  quickly 
lost  the  little  relief  which  it  originally  afforded,  so  that  the 
patient  was  in  a  state  of  constant  mental  and  physical 
unrest  which  preyed  upon  her  night  and  day,  disturbed 
her  sleep  and  harassed  her  when  awake. 

The  deep  reflexes  of  the  right  arm  and  leg  were  some- 
what more  active  than  the  corresponding  reflexes  upon 
the  left  side.  The  abdominal  reflexes  were  absent,  due 
probably  to  the  fact  that  the  abdomen  was  greatly  dis- 
tended b}^  a  large  cystic  fibroid  of  the  uterus.  There  was 
no  Babinski  on  either  side  and  no  pathological  reflex 
of  any  kind.  The  blood  and  urine  examinations  were 
negative.  The  spinal  fluid  was  not  examined. 

At  the  end  of  two  months,  it  became  necessary  to 
interfere  surgically  for  a  pelvic  condition  which  seemed 
to  jeopardize  the  patient's  life.  In  consequence,  a  laparo- 
tomy was  performed,  the  operation  being  a  short  one, 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS      33 

lasting  only  one  hour,  gas,  ether  and  oxygen  being  the 
anesthetics.  The  patient,  however,  never  regained  con- 
sciousness and  died  in  thirty-six  hours. 

This  case  was  the  subject  of  several  consultations 
and  much  difference  of  opinion.  B}^  some  it  was  con- 
sidered as  a  purely  functional  disorder,  having  the 
character  of  a  hysterical  tremor.  This  supposition  was 
substantiated  by  the  fact  that  the  patient,  prior  to  her 
illness,  had  been  engaged  in  war  work  among  soldiers 
returning  from  France,  many  of  whom  were  suffering 
from  "shell-shock."  Ultimately,  however,  the  clinical 
features  of  the  disease  were  too  definite  to  leave  room 
for  doubt  in  the  matter  of  its  close  correspondence  to  a 
typical  Parkinsonian  syndrome.  The  case  is  remarkable 
for  the  rapid  development  of  its  paralysis  agitans  features 
as  well  as  for  the  absence  of  any  conspicuous  period  of 
lethargy  or  somnolence. 

Case  IX,  Mr.  B.,  forty-two  years  of  age,  married, 
merchant.  The  course  of  the  disease  in  this  patient 
stands  out  in  pronounced  contrast  to  the  two  cases 
already  cited.  Although  a  definite  Parkinsonian  syndrome 
developed,  its  full  evolution  was  slow  and  its  course 
short,  the  patient  making  a  complete  recovery. 

During  the  summer,  Mr.  B.  had  complained  of  some 
intestinal  disturbance,  was  predisposed  to  lassitude  and 
some  disinclination  to  participate  in  his  usual  occupation 
and  amusements.  In  the  early  part  of  December,  it  was 
discovered  that  he  was  suffering  from  a  tapeworm. 
Other  than  this,  his  previous  history  contained  nothing 
of  particular  note,  as  he  had  always  been  a  man  who 
enjoyed  good  health  and  was  unusually  active.  He  did 
not  suffer  from  influenza  so  far  as  he  and  his  family 
can  recall. 

3 


34  EPIDEMIC    ENCEPHALITIS 

In  January,  he  went  to  a  sanitarium  to  take  vermi- 
fugic  treatment,  which  proved  successful  in  all  respects. 
Several  days  after  this  treatment,  instead  of  feeling 
improved,  he  complained  that  he  was  no  better;  in  fact, 
he  thought  he  felt  much  worse  than  before.  He  showed  no 
disposition  to  get  up  and  be  about  but  preferred  to 
remain  in  an  inert  if  not  semistuporous  condition  most 
of  the  time.  He  had  no  particular  restlessness  nor  did 
he  show  any  mental  disturbance,  but  his  conduct  was 
marked  by  an  unusual  indifference  to  his  surroundings. 
After  remaining  for  one  week  in  this  condition,  he  began 
to  see  double,  while  his  ph3'^sician  noted  that  there  was 
a  slight  palsy  of  the  right  side  of  the  face.  His  indifference 
increased;  he  seemed  to  have  lost  all  initiative  and  noth- 
ing succeeded  in  gaining  or  holding  his  attention.  He 
was  neither  stuporous  nor  comatose;  when  addressed 
he  would  respond  in  a  listless  manner. 

He  could  be  aroused  and  made  to  get  out  of  bed.  Upon 
such  occasions  his  physician  noticed  that  the  attitude 
of  his  body,  the  position  of  his  arms  and  head,  the  expres- 
sion in  his  face,  and  his  movements  in  walking  were 
strikingly  similar  to  the  appearances  of  paralysis  agitans 
without  the  tremor. 

The  patient  was  seen  in  consultation  and  the  diagnosis 
of  brain  tumor  was  made. 

At  the  end  of  four  weeks,  however,  there  appeared 
in  the  left  foot  a  tremor  typical  of  paralysis  agitans. 
This  slowly  extended  in  the  course  of  the  next  few  days 
until  it  involved  the  entire  left  leg  and  finally  manifested 
itself  to  a  slight  degree  in  the  left  hand  and  forearm. 

Neurological  examination  at  this  time  showed  a 
patient  with  a  characteristic  wax-mask  expression,  in 
addition  to  which  there  was  a  shght  facial  palsy  upon  the 
right  side  and  an  oc'casion;d  diplopia  due  undoubtedly 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS      35 

to  a  weakness  of  the  right  oculomotor  nerve.  There  was 
a  slight  degree  of  ptosis  of  both  eyelids. 

The  tremor  in  the  left  foot  and  leg  was  unquestionably 
of  the  agitans  type,  not  only  in  its  rate  and  amplitude, 
but  also  because  it  occurred  during  rest  and  disappeared 
during  action. 

The  reflexes  on  the  two  sides  were  active  and  equal. 
There  were  no  pathological  reflexes  observed,  either 
deep  or  superficial,  although  there  was  a  slight  tendency 
toward  increase  in  tone  of  the  muscles  upon  the  left 
side.  The  patient  had  some  festination  in  the  gait  and 
complained  of  a  sense  of  procursion. 

Sensibility  was  normal  in  all  qualities,  and  the  special 
senses,  with  the  exceptions  already  noted,  were  intact. 

The  patient  continued  to  be  apathetic  and  generally 
somnolent  for  several  weeks,  but  by  degrees  these 
symptoms  disappeared,  and  at  the  end  of  two  months 
not  only  the  tremor  and  stiffness  of  the  muscles  but  the 
Parkinsonian  attitude  and  expression  had  entirely 
disappeared. 

This  patient  did  not  have  fever  at  any  time  during  his 
disease 

His  urine  and  spinal  fluid  were  negative.  Eventually 
he  made  what  is  considered  a  complete  recovery  and  is 
now  in  a  state  of  health  which  he  himself  beheves  to  be 
normal. 

Case  X  Miss  H.  M.  H.,  thirty-eight  years  of  age, 
office  worker.  Coincidently  with  the  onset  of  her  last 
menstrual  period,  March  1,  1919,  she  suddenly  became 
excessively  nervous,  could  not  sleep  at  night  and  was  in 
a  state  of  depression  which  made  it  impossible  for  her  to 
attend  to  business.  She  believes  her  menstrual  period 
was  quite  normal  and  that  she  did  not  suffer  at  that  time 


36  EPIDEMIC    ENCEPHALITIS 

or  previously  from  illness  which  in  any  way  resembled 
influenza.  In  fact,  she  is  quite  certain  that  she  had  not  had 
the  influenza  during  the  past  winter;  and  up  to  the  time  of 
her  present  illness  she  had  been  carrying  on  her  work 
with  her  usual  energy  and  application.  Almost  imme- 
diately upon  the  onset  of  her  illness,  she  noticed  a  great 
disquietude,  especially  in  her  lower  extremities.  She  found 
she  could  not  get  them  in  any  comfortable  position  but 
was  compelled  to  move  them  about  continually  from 
one  position  to  another.  She  also  noticed  that  her  move- 
ments became  much  more  slow  and  deliberate  and  that 
whereas  she  had  always  been  alert  and  active,  she  now 
felt  stiff  and  fixed  as  if  molded  into  an  attitude  out  of 
which  it  was  difficult  for  her  to  extricate  herself.  She  had 
a  definite  sense  of  procursion  and  thinks  that  she  could 
run  ])etter  than  she  walks.  This  proves  to  be  the  fact, 
and  when  she  starts  running  it  is  difficult  for  her  to  come 
to  a  stand.  Her  attitude  and  expression  are  typically 
Parkinsonian;  after  the  first  week  of  her  present  illness, 
she  observed  a  tendency  to  a  tremor  appearing  in  her 
hand,  and  more  noticeably  in  her  left  foot.  This  sub- 
sequently extended  so  that  it  involved  the  entire  left 
leg.  The  tremor  came  on  especially  when  she  was  sitting 
down  and  when  the  leg  was  at  rest.  It  was  not  notice- 
able while  walking  or  standing.  About  this  time  there 
appeared  over  her  entire  l^ody  a  rash  which  she  said  was 
not  unlike  hives. 

A  neurological  examination  made  at  the  end  of  the 
fourth  week  of  her  illness  showed  a  young  woman  looking 
and  acting  in  all  respects  like  a  typical  case  of  paralysis 
agitans.  She  sat  immobile  and  then  suddenly  got  up  and 
walked  about  as  if  distressed,  although  her  movements 
were  slow.  There  was  a  suppression  of  almost  all  facial 
expression  and  of  all  automatic  associated  movements. 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS      37 

When  she  got  up  or  sat  down  it  was  almost  as  if  her  body 
were  one  piece.  She  walked  slowly  with  no  automatic 
associated  movements  in  the  arms.  Tests  of  coordination 
and  skilled  acts  were  normal,  save  for  a  marked  slowing 
down  of  all  movements.  Her  voice  was  monotonous  and 
toneless.  When  at  rest  there  was  a  definite  Parkinsonian 
tremor  in  the  left  leg  and  foot.  The  reflexes  were  normal. 
There  was  some  increase  in  muscle  tone,  especiall}'  on 
the  left  side  of  the  bod3^ 

All  types  of  somesthetic  sensibihty  were  intact. 

The  Cranial  Xerves.  The  olfactory  sense  was  normal. 
The  vision  seemed  fair;  the  fields  were  normal.  The  fundi 
showed  a  sUght  blurring  in  the  upper  margin  of  the  right 
disc.  The  pupils  were  unequal,  the  right  l)eing  larger  than 
the  left.  The}'  were  round  and  regular  and  central  in  posi- 
tion. There  was  a  slight  hippus.  Both  pupils  reacted  to 
light  and  convergence,  the  left  more  actively  than  the 
right.  There  was  no  stra])ismus  or  other  almormal  move- 
ments of  the  eye. 

The  acoustic  nerve  was  normal  and  so  also  were  the 
trigeminus,  facial,  glossopharj'ngeus  and  vagus,  spinal 
accessory  and  hypoglossal  nerves. 

The  patient's  mental  condition  became  so  distressing 
that  it  was  necessary  to  send  her  to  a  sanitarium.  Here 
she  had  several  severe  hysterical  attacks,  but  subse- 
quently became  calmer  and  has  recently  shown  some 
slight  improvement  in  all  of  her  symptoms. 

This  case  has  its  interest  in  the  fact  that  the  Parkin- 
sonian sj-ndrome  developed  apparently  without  any 
background  of  general  systemic  involvement,  there 
being  no  history  of  temperature  or  other  signs  of  acute 
infection.  Furthermore,  the  absence  of  any  pronounced 
lethargy  and  the  apparent  substitution  for  it  of  marked 
restlessness,  insomnia  and  physical  disquietude  give  a 


38  EPIDEMIC    ENCEPHALITIS 

turn  to  the  disease  which  is  quite  unusual  when  compared 
with  the  other  cases  of  this  type  already  reported. 

Case  XI.  Mr.  G.  G.,  sixty  years  of  age,  merchant. 
During  the  winter  of  1918-19,  he  had  the  influenza 
twice,  the  first  attack  of  which  was  complicated  by  lobar 
pneumonia.  He  made  a  complete  and  good  recovery 
after  each  attack  and  was  gradually  regaining  his  strength 
when  it  was  noticed  that  he  began  to  lose  his  usual 
interest  in  his  surroundings  and  lapsed  into  an  apathetic 
condition.  Every  effort  was  made  to  arouse  him  from  this 
state,  but  without  success.  He  had  no  actual  lethargy, 
but  he  slept  much  longer  and  apparently  more  deeply 
than  was  his  custom.  He  would  sit  about  the  house  most 
of  the  day  without  manifesting  interest  in  his  customarj^ 
pursuits.  All  of  his  motor  activities  became  decidedly 
slower  and  more  deliberate.  His  gait  was  somewhat  shuf- 
fling in  character  and  he  noticed  a  desire  when  walking  to 
hasten  his  steps;  in  fact  he  felt  like  running  most  of  the 
time  and  could  actually  run  much  better  than  he  could 
walk.  His  wife  and  friends  noticed  a  pronounced  change 
in  his  expression.  His  face  had  a  fixed  look.  His  voice 
grew  feeble  and  monotonous.  At  the  end  of  a  month,  it 
was  difficult  for  him  to  get  about,  not  alone  because  his 
movements  were  slow,  but  also  because  of  the  great 
fatigue  which  any  muscular  exertion  caused  him. 

Neurological  examination  at  this  time  showed  a  well- 
preserved  and  robust  man  lying  supine  in  bed,  unable  to 
rise  without  assistance,  and  quite  as  unable  to  turn 
himself  from  side  to  side  in  bed.  He  complained  bitterly 
of  a  sense  of  disquietude  in  his  legs,  and  expressed  the 
wish  to  move  them  frequently  about  in  the  bed.  In  this 
way  only  was  he  able  to  be  comfortable.  His  coordi- 
nation was  normal.  There  was  no  tremor  in  any  part  of 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS      39 

his  body.  His  reflexes  were  equal  on  the  two  sides,  both 
deep  and  superficial,  and  no  pathological  reflexes  were 
observed.  Upon  testing  his  muscles,  the  tone  presented 
a  marked  increase  in  all  of  the  muscles  of  both  upper 
and  lower  extremities.  All  automatic  associated  move- 
ments were  suppressed. 

Somesthetic  sensibility  was  normal. 

Cranial  Nerves.  The  nerves  of  special  sense  were 
intact.  There  was  a  slight  weakness  and  flattening  of  the 
right  side  of  the  face  and  the  patient  reported  that  in  the 
early  part  of  his  illness  he  had  suffered  from  a  transitory 
diplopia. 

The  trigeminus,  glossopharyngeus  and  vagus,  spinal 
accessory  and  hypoglossal  nerves  were  normal.  On  the 
day  of  the  examination  the  patient  manifested  a  ten- 
dency to  sleep,  which  was  more  pronounced  at  this  than 
at  any  other  time  during  his  illness.  He  had  no  tempera- 
ture; the  pulse  and  respiration  were  normal.  At  no  time 
during  his  illness  had  there  been  fever  or  other  evidence 
of  systemic  disturbance. 

The  laboratory  findings  were  not  reported  in  this  case, 
and  the  patient  has  remained  in  practically  the  same 
condition  for  the  past  few  weeks. 

This  group  of  cases  has  its  chief  interest  in  the  fact 
that  all  developed  clearly  defined  Parkinsonian  symp- 
toms. Four  of  these  cases,  in  addition  to  the  suppression 
of  the  automatic  associated  movements,  the  slowness  of 
somatic  movement,  the  characteristic  attitude  and 
facies,  presented  the  agitans  tremor. 

One  case,  however,  having  all  of  the  other  cardinal 
symptoms,  had  no  tremor. 

Two  of  the  five  cases  developed  a  moderate  degree  of 
somnolence  during  the  course  of  the  disease;  on  the  other 
hand,  three  of  these  patients  showed  a  marked  restless- 


40  EPIDEMIC    ENCEPHALITIS 

ness,  not  onlj^  at  the  beginning  of  the  disease,  but  more 
or  less  throughout  its  entire  course,  a  fact  which  makes 
them  stand  out  in  contrast  to  the  other  types  of  epi- 
demic encephahtis  already  described. 

One  of  these  cases  ran  a  fatal  course  after  several 
weeks'  duration,  with  a  marked  sustained  elevation  of 
temperature  and  a  sharp  rise  during  the  few  days  pre- 
ceding death. 

One  patient  died  due  to  an  intercurrent  operation. 

One  made  a  rapid,  complete  recovery,  and  two  others 
are  still  suffering  from  the  effects  of  the  disease. 

Three  of  the  patients  had  suffered  from  an  attack  of 
influenza  a  short  time  before  the  onset  of  the  encepha- 
litis; two,  however,  did  not  give  any  such  history. 


CHAPTER  V 


POLIOENCEPHALITIC    TYPE 


In  this  subgroup,  of  which  many  instances  have  l)e(>n 
reported,  the  authors  have  encountered  two  cases.  This 
group  is  recognized  because  the  essential  symptoms  of 
the  disease  confine  themselves  almost  wholly  to  the 
local  results  of  the  polioencephalitis,  usually  of  a  light 
grade,  and  causing  a  paralysis  of  one  or  more  of  the 
cranial  nerves.  The  oculomotor  (third  nerve)  and  the 
facial  nerve  are  most  connnonly  affected,  either  in  com- 
bination or  separately.  Lethargy,  stupor  or  somnolence 
were  not  prominent  in  this  group,  although  a  pronounced 
asthenia  of  considerable  duration  was  such  a  conspicuous 
clinical  feature  as  to  lead  to  the  supposition  that  the 
eases  might  in  reality  be  myasthenia  gravis  pseudopara- 
lytica.  Upon  investigation,  however,  it  was  definitely 
shown  that  such  was  not  the  fact  and  that  cases  of  this 
polioencephalitic  tj'pe  belonged,  in  all  probability,  to 
a  mild  or  even  abortive  form  of  epidemic  encephalitis. 

Case  XII.  Mr.  A.  L.  Age  sixty-three,  married,  mer- 
chant. In  January  1919,  after  many  months  of  active 
and  exacting  business  engagements  the  patient  became 
so  extremely  exhausted  that  he  consulted  his  ph^^sician. 
He  was  advised  to  give  up  business  for  a  time  and  leave 
the  city  in  order  to  rest  and  get  the  benefit  of  a  complete 
change.  The  following  morning  his  physician  was  again 
called,  because  the  patient  said  he  was  suffering  from 
some   disturbance  in   speech   which   he   thought   to   be 

41 


42  EPIDEMIC    ENCEPHALITIS 

aphasia  and  probably  due  to  a  stroke.  He  was  particu- 
larly alarmed  because  on  the  previous  evening  when  he 
had  been  at  the  theatre,  he  was  struck  by  the  fact  that 
he  was  troubled  with  double  vision.  This  diplopia  per- 
sisted until  the  next  day,  although  in  the  morning  upon 
waking  up  he  found  he  was  quite  free  from  it.  It  returned, 
however,  after  he  had  attempted  to  read  the  morning 
papers.  At  this  time  when  seen  by  his  physician  it  was 
noticed  that  he  presented  a  bilateral  facial  paralysis 
involving  all  three  branches  of  the  facial  nerve  on  both 
sides.  This  paralysis  accounted  for  his  difficulty  in  speech, 
for  he  talked  as  one  would  if  a  finger  were  pressed  into 
either  cheek.  A  slight  degree  of  ptosis  of  both  upper 
eyelids  was  also  present.  He  was  advised  to  leave  the 
city  at  once  for  the  seashore.  This  trip,  however,  was 
not  successful,  for  on  the  second  day  his  asthenia  in- 
creased so  much  that  he  became  alarmed  and  had  what 
seems  to  have  been  a  nervous  chill,  with  acute  indigestion. 

Neurological  examination  at  this  time  showed  a  man 
in  a  much  enervated  condition,  fully  cognizant  of  his 
environment,  able  to  be  up  and  about,  and  thoroughly 
to  cooperate.  His  gait  showed  nothing  peculiar,  but  his 
face  had  the  characteristic  expression  of  a  bilateral 
facial  paralysis.  There  was  a  marked  epiphora  of  tears 
and  a  tendency  to  sialorrhea.  His  gait  was  normal.  Mus- 
cular strength  and  coordination  were  good.  There  were 
no  defects  in  skilled  movements.  His  reflexes,  deep  and 
superficial,  were  normal  and  active.  There  were  no  ab- 
normal, involuntary  acts,  such  as  tremors  or  twitchings, 
and  all  automatic  associated  movements  were  intact. 

General  sensibility  was  normal,  as  were  all  of  the  cra- 
nial nerves  with  the  exception  of  the  seventh  on  both 
sides.  The  electrical  reactions  of  the  facial  muscles, 
both  direct  and  indirect,  showed  a  fairly  active  response 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS      43 

to  the  faradic  current  and  the  normal  galvanic  contrac- 
tion formula. 

The  asthenia  which  was  such  a  pronounced  symptom 
in  the  early  part  of  the  disease  has  gradually  disappeared. 
The  facial  palsj^  is  slowly  improving,  although  this  has 
persisted  for  sixteen  weeks. 

Case  XIII.  Air.  A.  G.  A.,  thirty-six  years  of  age; 
clerk.  During  the  time  when  a  number  of  patients  were 
confined  in  a  suburban  hospital  suffering  from  the  in- 
fluenza, this  patient  was  admitted  because  he  had  been 
slighth'  delirious  and  had  had  a  rise  of  temperature  to 
102°  which  lasted  for  several  days.  Upon  the  disappear- 
ance of  the  acute  symptoms  he  manifested  a  paralj'sis 
of  both  oculomotor  nerves  leading  to  a  slight  degree  of 
ptosis  and  external  strabismus.  The  right  side  of  the  face 
showed  some  flattening  in  its  middle  and  lower  portions, 
while  the  activit.y  of  the  frontalis  upon  the  right  side 
was  less  vigorous  than  that  upon  the  left.  This  patient 
developed  no  further  sjanptoms,  and  a  neurological  ex- 
amination made  on  the  fourth  day  of  his  illness  showed 
no  evidence  of  pathological  changes  in  his  nervous  sj's- 
tem  other  than  those  which  have  already  been  noted. 
He  suffered  from  an  asthenia  of  a  mild  grade  which 
lasted  for  about  a  month.  His  blood,  spinal  fluid  and 
urine  showed  nothing  abnormal.  In  six  weeks  he  was 
sufficiently  improved  to  enable  him  to  return  to  his 
business,  and  since  that  time,  with  the  exception  of  a 
brief  attack  of  severe  sciatica  on  the  left  side,  he  has 
enjoyed  normal  health. 

Both  of  these  cases  may  be  taken  to  represent  the 
strictly  focal  expression  of  a  polioencephalitis  of  mild 
degree.  The  inflammation  touched  the  nervous  system 
but  lightly  and  in  restricted  areas.  In  one  case  the  in- 


44  EPIDEMIC    ENCEPHALITIS 

volvement  of  the  cranial  nerve  nuclei  was  of  considerable 
sevei'ity  and  determined  a  slow  convalescence;  in  the 
other  instance,  however,  the  affection  of  the  motor  cells 
must  have  been  slight,  for  the  recovery  was  rapid  and 
complete.  These  cases  may,  therefore,  be  taken  to  indi- 
cate the  possibility  of  an  abortive  form  of  the  disease, 
one  in  which  the  involvement  is  so  light  as  to  occasion  a 
transitory  clinical  outline  of  the  more  severe  type  and  to 
permit  a  restitutio  ad  integram  almost  before  the  symp- 
toms were  well  enough  defined  to  attract  attention. 
In  one  case  there  was  a  general  systemic  reaction  as 
shown  by  the  slight  rise  in  temperature;  in  the  other 
case  no  such  reaction  occurred.  It  is  of  further  interest 
to  note  that  in  neither  case  was  it  possible  to  obtain  a 
history  of  influonza. 


CHAPTER  VI 

ACUTE    ANTERIOR    POLIOMYELITIC    TYPE 

Case  XIV.  Over  a  year  ago  one  of  the  authors''^  re- 
ported the  case  of  a  child  four  years  of  age  whose  mother 
stated  that  he  had  wasting  of  the  right  leg,  dragging  of 
the  right  foot,  and  weakness  of  the  right  leg,  particularly 
when  walking  or  running,  and  especially  when  walking 
any  distance.  This  child's  trouble  occurred  during  the 
last  epidemic  of  poliomyelitis  which  swept  over  New  York 
City  in  1916.  The  child  left  New  York  for  Liverpool  in 
September,  1916.  On  the  last  days  of  his  trip  he  com- 
plained of  feeling  ill  and  his  body  seemed  hot.  He  was 
seen  by  an  English  physician,  who  made  the  diagnosis 
of  infantile  paralysis,  upon  hearing  that  the  child  had 
come  from  New  York.  On  the  second  day  of  his  illness, 
the  patient  passed  into  a  deep  sleep,  in  which  condition 
he  remained,  not  even  arousing  to  take  food,  for  the 
next  fourteen  days.  The  mother  took  the  child  to  the 
hospital  and  placed  him  upon  a  bed  on  his  right  side. 
Each  time  she  called  to  see  him  he  was  still  in  the  same 
position.  After  fourteen  days  the  boy  made  his  first 
sound,  calling  his  mother.  The  child  was  unable  to  hold 
up  his  head  without  assistance  for  six  weeks.  He  sat 
up  alone  for  the  first  time  in  February,  1917,  and  two 
weeks  later  he  was  able  to  stand.  Since  that  time  he  has 
gradually  improved,  the  right  leg  remaining  much  smaller 
and  softer  than  the  left.  With  the  exception  of  considera- 
ble atrophy  and  a  marked  hypotonus  of  the  right  lower 
extremity,  the  neurological  examination  made  in   191.S 

45 


46  EPIDEMIC    ENCEPHALITIS 

showed  nothing  abnormal  in  the  patient.  There  is  no 
record  of  the  patient's  hospital  findings,  so  it  is  impossible 
to  state  whether  the  child  suffered  from  an  ophthal- 
moplegia or  whether  he  had  any  cranial  nerve  involve- 
ment. At  the  time  the  case  was  considered  to  be  one  of 
acute  poliomyelitis,  and  this  opinion  was  undoubtedly 
greatly  influenced  ])y  the  fact  that  the  illness  occurred 
during  a  wide-spread  and  virulent  epidemic  of  this  dis- 
ease, during  which  clinical  imagination  was,  perhaps, 
too  keenly  alert  in  the  recognition  of  the  disorder  then 
epidemic. 

This  condition  of  prolonged  somnolence  associated 
with  a  lower  motor  neuron  type  of  paralysis  affecting 
the  leg,  created  much  discussion,  although  it  was  the  final 
opinion  of  the  physicians  who  had  an  opportunity  to 
study  the  case  that  the  diagnosis  was  an  atypical  polio- 
myelitis. In  no  other  way  did  it  seem  possible  to  explain 
the  unusual  and  prolonged  somnolence.  It  is  our  present 
belief  that  the  case  does  in  reality  belong  to  that  latter 
group  and  presents  that  rare  but  not  at  all  impossible 
combination  of  symptoms,  namely,  the  simultaneous 
involvement  of  brain  and  spinal  cord.  It  is  noteworthy, 
however,  that  in  the  majority  of  cases  of  encephalitis,  the 
spinal  cord  is  but  little  involved,  and  conversely,  by 
far  the  greater  proportion  of  acute  poliomyelitis  cases 
show  little  or  no  involvement  of  the  brain  stem.  Par- 
ticular emphasis  is  laid  upon  this  fact,  and  the  authors 
desire  to  call  special  attention  to  this  case  of  infantile 
paralysis  which  occurred  during  the  height  of  a  virulent 
epidemic  of  acute  anterior  poliomyelitis  and  yet  had  one 
of  the  most  prominent  symptoms  associated  with  epi- 
demic encephalitis,  i.e.,  prolonged  somnolence. 


CHAPTER  VII 

POSTERIOR    POLIOMYELITIC   TYPE 

So  far  as  the  recorded  cases  show  at  the  present  time, 
this  type  presents  a  unique  variety  of  the  disease  whose 
chief  characteristic  is  an  inflammatory  affection  involv- 
ing the  dorsal  root  gangha — in  other  words,  producing  an 
acute  posterior  pohomj^elitis.  The  authors  have  encoun- 
tered but  a  single  instance  of  this  tj^pe. 

Case  XV.  Miss  M.  S.  Age  thirty-nine  years.  The  pa- 
tient's previous  history  is  not  important  in  her  present 
condition.  She  has  suffered  from  no  serious  illness,  and 
so  far  as  she  is  able  to  state,  did  not  have  influenza 
during  the  past  winter.  Her  family  history  is  negative. 

On  January  1,  1919,  the  patient  attempted  in  the 
morning  to  arise  from  bed,  but  upon  standing  up,  fell 
to  her  knees,  and  only  with  great  effort  was  she  able  to 
return  to  bed.  This  incident  did  not  seem  to  have  alarmed 
her  much  or  to  have  attracted  her  attention  especially. 
She  knew  that  she  felt  weak  and  sleepy  and  so  decided 
to  remain  quiet.  In  a  short  time  she  fell  asleep  and  for 
the  next  three  weeks,  she  slept  most  of  the  time.  She 
could  be  aroused  to  take  her  meals  but  manifested  little 
interest  in  her  surroundings.  When  seen  by  her  physician, 
her  condition  was  thought  to  be  one  of  a  nervous  break- 
down, possibly  an  hysteria.  Her  temperature  was  not 
taken  and  it  is  believed  that  she  had  no  elevation  of 
temperatuie  during  her  acute  illness.  As  she  began  to 
recover  at  the  end  of  three  weeks,  she  noticed,  upon 

47 


48  EPIDEMIC    ENCEPHALITIS 

attempting  to  read,  that  the  letters  blurred,  and  when 
looking  at  a  distance  she  was  conscious  of  double  vision. 
This,  however,  rapidly  disappeared,  so  that  in  the 
course  of  a  week  she  could  read  for  a  short  space  of  time 
without  seeing  double;  but  as  soon  as  she  became  at  all 
fatigued,  the  double  vision  returned.  She  also  noticed 
a  tingling  and  burning  sensation  which  was  very  disa- 
greeable and  at  times  painful  upon  the  left  side  of  her 
face  in  an  area  which  came  exactly  up  to  the  midline 
and  followed  in  all  its  boundaries  the  cutaneous  innerva- 
tion of  the  trigeminal  nerve.  In  the  region  in  which  she 
suffered  this  painful  sensation,  there  appeared  a  number 
of  small  herpetic-like  eruptions  which,  however,  never 
assumed  the  full  character  of  herpes;  these  small  erup- 
tions were  very  sensitive  to  the  touch,  to  the  air  and  to 
cold  water.  At  the  end  of  ten  weeks  the  rash  was  still 
faintly  visible  and  was  discretely  limited  to  the  area  of 
innervation  upon  the  skin  of  the  left  trigeminal  nerve. 
About  this  time  the  patient  began  to  complain  of  a  ting- 
ling and  burning  sensation  on  the  dorsal  aspect  of  the 
right  leg,  corresponding  to  sacral  dermatomes  2,  3  and  4. 
This  she  described  as  similar  in  all  respects  to  the  sen- 
sation in  the  left  side  of  her  face,  although  no  eruption 
had  as  yet  been  detected  in  this  area  on  the  right  leg. 

The  neurological  examination  showed  that  the  reflexes 
were  equal  and  active  upon  the  two  sides,  both  deep  and 
superficial.  The  muscle  tone  was  normal.  There  was  no 
paralysis  or  loss  of  strength  and  no  incoordination. 
The  muscular  status  was  normal. 

Somesthetic  sensibility,  with  the  exception  of  the  left 
trigeminal  area  and  the  regions  of  innervation  correspond- 
ing to  sacral  dermatomes  2,  3  and  4  upon  the  right  leg, 
was  normal.  In  addition  to  the  pain  and  dysesthesia 
described  in  the  two  affected  cutaneous  zones,  there  was 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS      49 

a  marked  hyperalgesia  in  the  trigeminal  area  of  the  left 
side  and  the  cutaneous  zones  on  the  back  of  the  right 
log.  Paresthesia  was  also  present  in  these  regions,  both 
cold  and  heat  being  interpreted  as  pain,  and  a  slight 
stroking  with  cotton  wool  giving  a  distressing  sensation. 
This  case,  whose  cardinal  symptoms  were  lethargy, 
ophthalmoplegia  and  zoster-like  involvement  of  the 
left  side  of  the  face  and  the  right  leg,  may  be  regarded  as 
a  typical  example  of  acute  encephalitis.  Its  unusual  clini- 
cal feature  arises  from  the  fact  that  the  dorsal  root 
ganglia,  certainly  the  Gasserian  upon  the  left  side  and 
probably  the  dorsal  root  ganglia  of  sacral  2,  3  and  4 
upon  the  right  side,  had  been  involved  in  an  inflammatory 
process. 


CHAPTER  VIII 

EPILEPTO-MANIACAL    AND  ACUTE  PSYCHOTIC  TYPES 

Case  XVI.  Mr.  G.  H.,  thirty-six  years;  clerk.  In  the 
latter  part  of  December,  1918,  this  patient  suffered  from 
influenza  with  severe  bronchial  involvement.  His  recovery 
was  unsatisfactory,  for  the  reason  that  he  seemed  to  pass 
from  a  respiratory  to  a  psychic  disturbance.  In  the  second 
week  of  his  illness,  he  became  unmanageable.  His  tem- 
perature still  remained  at  102°  and  103°.  He  had  some 
hallucinosis  as  well  as  certain  ill-defined,  unorganized 
delusions.  These  were  more  troublesome  at  night,  for 
during  the  day  he  slept  most  of  the  time.  For  several 
weeks  he  lay  in  this  lethargic  condition,  occasionally 
during  the  day  muttering  some  incoherent  words  or 
showing  a  partial  cooperation  when  aroused  to  take 
medication  or  food.  At  this  time  he  was  orientated  to 
time,  place  and  person.  At  the  end  of  two  weeks  his 
somnolence  during  the  day  became  more  profound,  while 
at  night  his  delirium  would  rise  at  times  to  a  point  at 
which  he  became  violent  and  destructive,  so  that  actual 
restraint  was  required.  During  these  periods  of  excitement 
he  manifested  definite  hallucinosis  and  delusions,  the 
latter  being  mostly  of  the  persecutory  form.  On  several 
occasions  he  managed  to  free  himself  from  his  restraint 
and  presented  such  maniacal  manifestations  that  it  was 
necessary  to  overcome  him  by  force  and  keep  him  under 
the  influence  of  narcotics.  In  the  fifth  week  of  his  illness, 
he  had  a  generalized,  epileptiform  convulsion,  which  was 
repeated  in  several  hours,  and  from  that  time  until  his 

50 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS      51 

death,  these  convulsions  continued  with  increasing 
frequency  and  severity.  His  temperature  slowly  rose  and 
after  being  in  a  status  epilepticus  for  several  hours,  he 
died  in  coma  after  an  illness  lasting  six  weeks. 

Neurological  examination  of  this  patient  showed  noth- 
ing of  localizing  significance.  The  motor  system  in  so 
far  as  it  could  be  adequately  investigated,  was  normal, 
except  for  a  slight  external  strabismus  of  the  right  eye, 
together  with  some  nystagmoid  movements  affecting 
both  eyes. 

The  blood  count  and  culture  were  negative  on  several 
tests.  The  first  lumbar  puncture  showed  a  spinal  fluid 
under  considerable  pressure  containing  a  slight  increase 
in  cells.  Upon  smear  and  culture  it  revealed  the  presence 
of  an  organism  which  was  regarded  as  a  diplostrepto- 
coccus.  This  finding,  however,  should  be  accepted  with 
much  reservation,  since  the  spinal  fluid  withdrawn 
several  days  later  and  tested  in  three  different  labora- 
tories, gave  no  such  results.  No  autopsy  was  obtained. 

ACUTE    PSYCHOTIC   TYPE 

Case  XVII.  F.  S.,  male,  age  thirty-six.  Admitted  to 
the  hospital  October  19,  1918,  with  a  diagnosis  of  in- 
fluenza and  bronchopneumonia,  and  the  final  diagnosis 
of  acute  encephalitis  and  acute  parotid  sialadenitis. 

On  October  15,  1918,  the  patient  was  seized  with  a 
chill  and  general  malaise.  He  felt  some  weakness  and 
had  headache  and  fever  with  pain  in  the  back.  On  exam- 
ination, the  patient  presented  much  prostration,  flushed 
face  and  rapid  breathing;  he  had  a  coated  tongue  and  a 
red  pharynx.  There  were  signs  of  bronchopneumonia 
in  the  lower  right  lobe  posteriorly.  There  was  some 
abdominal  distension. 


52  EPIDEMIC    ENCEPHALITIS 

Neurological  examination  showed  a  patient  very- 
apathetic,  lethargic  and  difficult  to  arouse.  There  was 
nothing  abnormal  in  the  cranial  nerves.  The  patient 
seemed  unable  to  protrude  the  tongue. 

Examination  of  the  blood  made  on  October  21st, 
showed  the  wh:te  cells  7,200;  polymorphonuclears  96 
per  cent;  large  mononuclears  2  per  cent  and  lymphocytes 
2  per  cent.  The  patient  slept  all  of  the  time  and  was  too 
somnolent  to  cooperate  in  any  examination.  There  was 
some  evidence  of  parotitis.  He  could  be  aroused  from  his 
lethargy  with  difficulty,  but  when  he  responded  at  all 
his  answers  and  actions  were  irrational.  During  the  next 
week  his  apathy  and  somnolence  increased  steadily, 
although  there  were  intervals,  especially  -at  night,  when 
he  gave  evidence  of  an  acute  psychosis.  He  evidently 
suffered  from  auditory  hallucinosis,  as  he  seemed  to 
hear  voices  and  reply  to  them.  Consciousness  was  much 
clouded  and  the  patient  became  entirely  disorientated 
during  such  intervals  as  when  he  was  aroused  to  take 
food.  During  the  night  he  manifested  a  vicious  tendency 
to  resist  all  efforts  to  care  for  him.  He  would  get  out  of 
bed,  urinate  on  the  floor,  and  insist  on  throwing  the  bed- 
clothes on  the  floor  or  out  of  the  window.  If  left  to  him- 
self, he  would  wander  about  the  ward.  Ultimately  he 
became  noisy  and  uncontrollable. 

On  the  28th  of  October,  the  lethargy  had  deepened 
into  a  stupor.  A  lumbar  puncture  made  at  this  time 
showed  a  clear  fluid  under  no  increase  of  pressure,  with  4 
lymphocytes,  globulin  reaction  negative,  Wassermann 
reaction  negative,  culture  sterile. 

It  now  seemed  impossible  for  him  to  articulate  or 
to  move  his  tongue  and  swallow.  The  reflexes  in  the 
upper  extremities  were  present  but  sluggish.  The  ab- 
dominal  reflexes   were   all   present   but   sluggish.    The 


itftli 

c.       ' 

;    D.v'fiiMk 

Day  0/  1U»4U 

UnrofD^ 

PUL.. 

Tui. 

170 

108«- 

160 

107?^ 

.1 
1501 

106a 

o; 

1 

1/3 

■  40,' 
1 

1055- 

■lb 

uo 

1042. 

i*) 

120 

103?^ 

%<> 

110 

1025 

»l 

100 

lOU 

Ik 

90 

100? 

X\ 

80 

99? 

IC> 

;o 

9«^ 

.0 

970 

^ 


, 

^ 

-     lo.. 

"-r 

" 

a 

as 

30 

as 

as 

30 

_>»_ 

as 

1 

15 

» 

U^tfD^       |g  S 

■ 

Imm 

III 

' 

\ 

_1^.      - 

1     _j_ 

'  ;■[  ' 

i 

i 

11 
it 

,» 

...  ■ 

1  '  ■ 

1 

M  ■ '  1 

■  '■ 

■ 

1 

-   1  '  . 
1  ■  1 

J_   J_  ' 

j       '   ' 

hi~ 

'  i 

i  ;  : 

.,. 

I  1     ■     ' 

: " :  1 

1  i 

11 

II    1-  !  1 

■  i : 

ii! 

!  !  1  '  1- 

~[ 

^...'■\., 

Mill 

1 

iM ! 

M  ,  :  i 

1  I  1,1  1 

■    '  1  ■! 

Ill: 

1  i  '  ■ 

1 

,  .^...^ 

,^ , 

1 1 ! ! ; 

i  i 

!■          i 

■  i  1 

1 

1  '  1 

hi' 

Roffl 

-  •  N'C- 

^i/S^ 

w 

iP           '■■ 

1     I  !  ;  . 

-■■u 

.__._ 

- 

I';,'' 

7'\ 

'i  I  '   '       '  l/-"-  \\''\ 

1. 

1 

'   :  •; 

1  'a 

■ 

^:'d  "' 

I  ^m^ 

1/1 /\ 

l<Vi'" 

•fi 

1     :  .    ■ 
1     ■    ■  ■ 

I't 

-^i';,-:- 

v:>"-<n\u\A 

'r'V-- 

^^.-' 

i"U 

1     !■■ 

1 1 

Mil 

ill 

\J.L/r 

\;-^^ 

^'■-N 

\  '    ■ 

->! 

r  1     • 

!  ■'  i  ■ 

, 

li 

Mi', 

1  i         1  ; 
1       '     ■  ' 

!■    '   II 

t  ,  :'"' 

..:,/  ■  i 

!  ' 

I 

■    !  ■!  1  ' 

: 

Hi 

.'    il 

+^'^ 

111: 

p '  ■  ■ 

,   !■' 

;  M 

■  1:* 

:,:  :  |.; 

' 

1    .|    l: 

1 

!  1 1 

1 

1-  ■ 

■1 

l;l:i'  i  i.:i 

IN  !  ■ ;  ! 

1  i  :.  ; 

1  ; 

.   1    ■:-'    1 

1  .  .■■ ; 

,  1  1 

M-:'-i 

CHART  III.     ACUTE  PSYCHOTIC  TYPE 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS      53 

knee-jerks  were  present  but  feeble,  the  right  being  shghtly 
more  active  than  the  left.  There  was  no  Babinski  nor 
any  modification  of  this  sign.  The  pupils  were  dilated, 
regular  and  equal,  but  reacted  sluggishly  to  light  and 
accommodation.  The  optic  discs  were  sharply  outlined. 
His  temperature  is  shown  in  Chart  III. 

On  October  30th  the  patient  passed  into  coma,  and  on 
November  1st  died.  No  autopsy  was  obtained. 


CHAPTER  IX 

« 

INFANTILE  TYPE    (NEONATORUM) 

It  seems  fitting  in  this  subgroup  to  mention  the  cases 
of  three  infants,  respectively  four,  four  and  six  weeks  of 
age;  all  of  these  cases  were  seen  at  the  Babies'  Hospital 
through  the  courtesy  of  Doctors  Robbins  and  Gold- 
bloom,  who  are  p/eparing  a  carefully  detailed  report  for 
later  publication.  In  the  clinical  picture,  these  patients 
corresponded  so  exactly  to  the  conditions  seen  in  aduUs 
suffering  from  acute  encephalitis,  that  there  can  be 
little  doubt  as  to  the  pathology  of  their  disease. 

The  interest  of  the  cases  lies  in  the  fact  that  their 
disease  began  at  such  an  extreme  early  age,  an  observa- 
tion, so  far  as  the  writers  know,  to  which  attention  has 
not  been  hitherto  called. 

Case  XVIII.  This  infant,  six  weeks  old,  without 
premonitory  symptoms,  suddenly  refused  to  take 
nourishment  and  passed  into  a  deep  sleep  in  which  he 
remained  for  two  weeks. 

During  this  period  it  was  necessary  to  feed  him  by 
tube.  Due  to  the  excellent  care  which  he  received,  he 
was  kept  alive,  but  when  he  began  to  show  a  return  of 
interest,  it  was  found  that  he  had  a  complete  paralysis 
of  the  left  side  of  the  face.  This  paralysis  has  persisted 
for  a  number  of  weeks  although  it  is  slowly  improving. 

Case  XIX.  This  patient,  four  weeks  old,  gave  a 
similar  history  to  that  of  the  one  already  described  and 
after  a   period   of  three  weeks'   somnolence,   ])ogan   to 

54 


CLINICAL   AND    PATHOLOGICAL   MANIFESTATIONS       55 

recover.  In  this  instance,  the  lower  and  middle  facial 
muscles  upon  the  left  side  were  found  to  be  paralyzed 
as  a  result  of  the  disease.  The  child  is  now  doing  well 
and  is  gradually  improving. 

Case  XX.  Another  infant,  four  weeks  old,  had  a 
similar  history  of  prolonged  somnolence  for  two  weeks, 
at  the  end  of  which  time  it  began  to  show  some  return 
of  interest.  Subsequently  it  was  found  to  be  suffering 
from  a  paralysis  of  the  left  side  of  the  face  and  a  motor 
paralysis  of  the  right  musculo-spiral  nerve,  giving  rise 
to  a  characteristic  wrist  drop  upon  that  side. 

These  three  cases  are  cited  in  brief  abstract  only  as 
they  will  be  described  later  in  extenso  by  the  pathological 
department  of  the  Babies'  Hospital.  The  writers  desire 
to  express  their  deep  appreciation  of  the  courtesy  and 
kindness  of  the  staff  of  the  Babies'  Hospital  which  made 
possible  the  observation  of  these  three  cases. 


CHAPTER  X 


DISCUSSION 


Critical  Analysis  of  the  Symptoms  and  Course  of  the 
Disease  in  the  Series  of  Cases  Described 

1.  Onset.  In  genei'al  it  may  be  said  that  the  onset  of 
epidemic  encephahtis  is  sudden  and  usually  occurs  with- 
out the  development  of  prodromata.  Eighteen  of  the 
twenty  cases  described  in  this  article  showed  such  a 
sudden  onset,  while  in  the  remaining  two,  there  was  a 
short  prodromal  period  characterized  by  general  malaise, 
asthenia,  slight  chilliness  and  a  rise  of  temperature. 
This  lasted  for  several  days  before  the  definite  symptoms 
of  the  disease  were  recognized. 

2.  Lethargy.  Profound  somnolence  approaching  stu- 
por was  the  most  common  clinical  feature  in  the  group 
of  cases  described.  This  lethargy  was  characterized  by 
the  fact  that  although  the  patients  seemed  to  be  sleeping 
soundly  and  to  be  oblivious  to  the  incidence  of  ordinary 
stimuli,  they  could  be  aroused  by  more  active  stimula- 
tion and  would  then,  for  a  short  time,  manifest  a  fairly 
clear  orientation  and  show  little  or  no  clouding  of  con- 
sciousness. This  alert  state,  however,  was  short  lived 
and  as  soon  as  the  effort  to  keep  the  patients  awake 
ceased,  they  would  lapse  back  into  the  deep  sleep  again. 
The  lethargy  was  of  varying  degrees  of  intensity;  in  some 
instances  it  was  extremely  light,  being  little  more  than 
a  continuous  drowsiness  from  which  the  patients  could 
be  aroused  without  much  difficulty.  In  other  cases,  how- 

56 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS      57 

ever,  the  somnolence  was  much  more  profound  and  it 
required  an  active  effort  to  awaken  the  patients.  Seven- 
teen of  the  cases  suffered  from  this  lethargy,  while  three 
of  them,  although  typical  of  the  disease  in  other  respects, 
at  no  time  showed  an  inclination  to  sonmolence  or 
drowsiness.  It  is  interesting  to  note  in  this  connection 
that  all  three  of  these  cases  belong  to  the  type  described 
in  the  subgroup  of  paralysis  agitans. 

3.  Cranial  Nerve  Palsies.  A  large  percentage  of  the 
cases  showed  involvement  of  one  or  more  of  the  cranial 
nerves,  fourteen  of  the  cases  presenting  such  affections. 
Of  these,  seven  were  confined  exclusively  to  the  oculomo- 
torius  nerve  (the  third  nerve).  Six  cases  presented  a 
combination  of  the  oculomotorius  and  facial  nerve  palsies, 
and  in  one  case,  which  rapidly  ran  a  fatal  course,  the 
third,  sixth,  ninth,  tenth  and  twelfth  cranial  nerves 
were  simultaneously  involved.  In  all  instances,  the 
cranial  nerve  palsies  were  of  the  lower  motor  neuron 
type.  Six  cases  of  this  series  presented  no  cranial  nerve 
involvement. 

4.  Temperature.  Some  degree  of  pyrexia  was  the  rule. 
It  is,  however,  not  an  essential  feature  of  the  disease. 
Numerous  observers  have  reported  cases  in  which  no 
temperature  has  been  observed  throughout  the  entire 
course  of  the  illness.  On  the  other  hand,  it  is  quite  possi- 
ble that  some  degree  of  fever  of  short  duration  may  be 
present  in  all  cases  but  escape  detection,  in  much  the 
same  way  as  in  poliomyelitis,  of  which  there  are  cases 
reported  without  elevation  of  temperature.  This  may 
be  due  to  the  fact  that  such  cases  did  not  come  under 
observation  at  a  time  when  the  temperature  might  be 
accurately  determined.  It  seems  probable  that  all  cases, 
even  of  the  milder  grades,  are  subject  to  changes  in 
temperature  at  some  time  during  the  course  of  the  disease. 


58  EPIDEMIC    ENCEPHALITIS 

Of  the  twenty  cases  of  this  series,  fourteen  ran  a  sus- 
tained temperature  beween  101°  and  102°,  with  several 
instances  showing  acute  exacerbations  much  above  this 
level  for  a  number  of  days  and,  indeed,  a  few  of  them  for 
a  number  of  weeks.  In  the  lethargic  type  a  temperature 
averaging  102°  seems  to  be  the  rule.  There  may,  more- 
over, be  sudden  elevations  to  a  much  higher  level  (105°, 
106°  or  even  107°),  the  temperature  range  having  the 
appearance  already  shown  in  Charts  I,  II  and  III. 

The  acute  psychotic  and  epilepto-maniacal  types 
show  a  tendency  to  a  decided  rise  in  temperature  which 
is  maintained  for  a  considerable  time. 

Of  the  five  cases  of  paralysis  agitans  type,  one  alone 
showed  a  distinct  and  prolonged  elevation  of  temperature. 
This  proved  to  be  a  fatal  case. 

In  the  milder  cases  of  the  lethargic  type,  the  elevation 
of  temperature  is  usually  of  short  duration.  In  the  more 
severe  cases,  however,  the  temperature  curve  may  run 
a  course  coincident  with  the  lethargy  and  begin  to  show 
an  inclination  to  return  to  normal  only  as  the  patient 
recovers  from  the  somnolence. 

In  those  types  of  the  disease  in  which  the  inflamma- 
tory process  is  confined  to  the  brain  stem,  the  tempera- 
ture does  not  seem  to  reach  an  unusually  high  level, 
even  in  fatal  cases,  while  in  the  posterior  poliomyelitic 
type  the  temperature  rise  may  be  so  evanescent  as  to 
escape  clinical  record. 

Such  cases  of  the  infantile  type  as  have  been  observed 
would  lead  to  the  supposition  that  the  pyrexia  is  not 
pronounced  and  is  usually  coincident  with  the  duration 
of  the  somnolence. 

The  pyrexia  seems  to  vary  directly  with  the  intensity 
of  the  infection,  both  as  to  the  degree  of  its  elevation 
and  its  duration. 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS      59 

5.  Tremor.  Seven  of  the  twenty  cases  presented  a 
distinct  tremor.  In  five  of  these,  the  tremor  in  its  rate, 
amplitude  and  general  conditions  was  of  the  paralysis 
agitans  type.  In  two  cases,  on  the  other  hand,  it  was  of  a 
much  finer  variety  and  made  itself  apparent  either  when 
the  patient  attempted  to  move  a  part  or  limb,  or  when 
the  same  was  passively  moved.  The  striking  appearance 
of  certain  of  the  other  cardinal  features  of  the  Parkin- 
sonian syndrome  in  conjunction  with  the  tremor  aided 
in  establishing  the  identity  of  the  tremor  itself.  The 
wax-mask  expression,  the  suppression  of  automatic 
associated  acts,  the  Parkinsonian  attitude,  the  monotony 
of  the  voice,  the  flexible  hypertonus  of  the  muscles,  the 
shuffling  and  festinating  gait,  were  so  unmistakable  as 
to  leave  no  doubt  with  reference  to  the  clinical  picture. 
In  every  instance,  the  distribution  was  that  of  a  hemi- 
tremor,  in  two  cases  involving  the  right  side  and  in  two 
others  the  left  side  of  the  body.  It  was  a  tremor  of  rest 
which  usually  disappeared  when  the  patient  was  in  deep 
sleep  but  in  nearly  every  case  would  make  its  reappear- 
ance when  the  patient  was  sleeping  lightly  or  was  about 
to  awaken.  One  case  had  all  of  the  characteristics  of  a 
paralysis  agitans  sine  agitatione.  Such  tremor,  therefore, 
as  was  noted,  belonged  for  the  most  part  to  the  paralysis 
agitans  type,  although  a  finer  and  more  rapid  oscilla- 
tion should  also  be  included  in  the  description  under  this 
heading. 

6.  Asthenia.  More  or  less  profound  and  general 
asthenia  was  observed  in  six  of  the  twenty  cases;  in 
fourteen,  however,  it  was  not  a  prominent  symptom.  In 
those  instances  in  which  it  did  occur,  it  was  conspicuous 
for  its  long  duration  and  also  for  the  tendency  for  the 
muscular  weakness  with  a  sense  of  general  debility  to 
return  upon  slight  exertion,  even  weeks  after  the  acute 


60  EPIDEMIC    ENCEPHALITIS 

symptoms  had  disappeared.  Some  of  these  patients,  when 
well  along  in  their  convalescence,  have  found  it  necessary 
to  go  to  bed  again  for  several  da3''s  at  a  time,  because 
their  usual  activities  completely  exhausted  them. 

7.  Restlessness.  As  if  replacing  the  lethargy,  restless- 
ness and  a  sense  of  disquietude,  which  led  the  patients  to 
feel  that  it  was  impossible  to  get  the  body  or  limbs  into 
any  comfortable  position,  especially  while  at  rest,  was  a 
symptom  which  occurred  in  five  of  the  twenty  cases. 
It  is  of  interest  to  note  that  this  restlessness  and  sense  of 
disquietude  were  present  in  all  but  one  of  the  five  cases 
belonging  to  the  paralysis  agitans  group,  and  the  fifth 
case,  showing  marked  restlessness,  was  that  of  a  patient 
whose  subsequent  history  seems  to  indicate  that  he  is 
developing  some  of  the  features  of  the  Parkinsonian 
syndrome. 

8.  Catalepsy.  An  unusual  hypertonus  in  the  muscular 
system  determining  fixed  positions  of  the  trunk  and  limbs 
as  well  as  of  the  facial  and  lingual  muscles,  was  a  striking 
feature  in  two  of  the  cases.  This  hypertonus  produced  a 
rigidity  which  had  some  of  the  elements  of  a  fiexibilitas 
cerea.  On  the  other  hand,  the  total  absence  of  any 
evidence  indicating  impHcation  of  the  pyramidal  system 
would  seem  to  place  the  responsibility  of  this  muscular 
change  outside  of  the  palliospinal  connection.  Indeed, 
this  symptom  has  been  credited  to  some  extrapyramidal 
system.  The  hypertonus  so  generally  seen  in  the  paraly- 
sis agitans  group  of  this  disease  undoubtedly  has  its 
explanation  in  the  disturbance  of  the  extrapyramidal 
connections.  Furthermore,  a  slight  but  still  discernible 
degree  of  hypertonus  was  observed  in  all  of  the  lethargic 
cases,  which  might  be  looked  upon  as  partial  involvement 
of  the  extrapyramidal  fibers. 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS       61 

9.  Spinal  Fluid.  The  spinal  fluid  was  carefull}'-  exam- 
ined in  fifteen  of  the  twenty  cases.  In  only  one  of  these 
was  there  anything  observed  which  could  be  considered 
as  possibly  pathological.  This  occurred  in  the  single  case 
in  which  on  one  lumbar  puncture  a  diplostreptococcus 
was  found  in  the  fluid  upon  incubation,  on  culture  and 
in  the  stained  smear.  Subsequent  tests  of  the  fluid  ob- 
tained on  another  lumbar  puncture  from  the  same  case 
showed  no  such  organism  to  be  present.  With  this  doubt- 
ful exception,  the  spinal  fluid  in  all  cases  was  sterile;  it 
contained  but  a  shght  increase  in  globulin  and  there  was 
no  marked  pleocytosis.  In  some  of  these  facts,  the  labora- 
tory findings  in  epidemic  encephalitis  stand  out  in  con- 
trast to  the  familiar  features  present  in  acute  anterior 
poliomyelitis.  Although  no  definite  organism  has  as 
yet  been  found  in  the  spinal  fluid  of  the  latter  disease, 
the  marked  pleocytosis  and  increase  in  globulin  have 
been  taken  as  significant  of  meningeal  irritation  or 
inflammation. 

COURSE   AND    DURATION    OF   THE    DISEASE 

The  average  duration  of  the  disease  in  so  far  as  it  may 
be  estimated  at  present,  is  about  eight  weeks.  This  figure, 
of  course,  included  a  number  of  cases  which  are  still 
improving  or  have  as  yet  shown  little  or  no  change  for  the 
better.  Some  cases,  on  the  other  hand,  may  terminate 
fatally  after  running  a  brief  course  of  a  few  days  or  as 
long  as  nine  weeks.  Many  cases  with  the  severest  symp- 
toms clear  up  rapidly.  There  is,  however,  a  tendency  for 
their  symptoms  to  reappear  and  in  one  or  two  cases  new 
symptoms  have  become  prominent  after  the  patient  had 
made  an  apparently  complete  recovery. 

Of  the  twenty  cases  included  in  this  report,  25  per  cent 
terminated  fatallj'. 


62  EPIDEMIC    ENCEPHALITIS 

These  figures  seem  to  represent  a  mean  between  the 
mortahty  rate  of  Economo  which  was  54  per  cent,  that 
of  Netter^^  which  was  46  per  cent,  that  of  Wilson  which 
was  15  per  cent,  and  that  of  Hall^^  who  lost  none  of  his 
sixteen  cases. 

Of  the  cases  of  this  series  who  have  survived,  roughlj'' 
15  per  cent  show  a  complete  recovery,  20  per  cent  are 
improving  slowly,  and  35  per  cent  are  either  at  present 
stationary  or  show  some  aggravation  of  their  former 
symptoms. 


CHAPTER  XI 


PROGNOSIS    AND    DIAGNOSIS 


Conservatism  should  be  used  in  giving  a  prognosis 
in  cases  of  any  type  of  this  disease.  Some  forms  of  it 
seem  to  be  more  prone  to  fatal  termination  than  others. 
In  general,  it  may  be  said  that  the  poliomyelitic  and 
mild  polioencephalitic  types  are  not  serious  with  respect 
to  life  and  usually  terminate  in  a  complete  recovery  after 
a  relatively  short  duration.  Cranial  nerve  palsies,  how- 
ever, especiall}^  where  the  facial  nerve  is  involved,  are 
somewhat  slower  in  repair  than  is  the  case  with  the  ordi- 
nary peripheral  facial  palsies. 

Ophthalmoplegias  are  generally  of  short  duration, 
but  tend  to  reassert  themselves  for  some  time  after 
recovery  has  been  established,  especially  when  the  pa- 
tient becomes  exhausted  or  fatigued. 

In  the  epileptomaniacal  and  acute  psychotic  types, 
the  condition  should  be  regarded  as  grave  and  not  of 
hopeful  prognosis  as  to  life. 

In  the  lethargic  type,  one  should  be  governed  largely 
by  the  intensity  of  the  somnolence.  This  however,  is  not 
the  only  index  which  may  serve  as  a  guide.  Many  of  the 
most  severe  cases  of  this  type  make  a  good  recovery  and 
they  should  be  considered  as  particularly  grave  only 
when  the  cranial  nerves  of  the  bulb  give  evidence  of 
involvement. 

The  prognosis  in  the  cataleptic  type  is  much  better 
than  the  general  impression  which  these  patients  actually 
convey  during  tlie  period  of  tluMr  illness.  Their  appear- 

63 


64  EPIDEMIC    ENCEPHALITIS 

ance  seems  to  certify  a  fatal  termination,  and  yet  a  num- 
ber of  these  cases  make  a  good  recovery.  In  our  series, 
one  case  of  the  cataleptic  type  is  still  living  and  one  of 
them  died. 

In  the  paralysis  agitans  type  of  the  disease,  it  is  perhaps 
too  early  at  this  time  to  state  definitely  what  outcome 
may  be  expected  in  every  case.  It  is  quite  certain  that 
complete  recovery  from  this  type  of  involvement  is 
possible,  but  whether  all  of  the  cases  manifesting  the 
Parkinsonian  syndrome  will  eventually  clear  up  is  a 
question  to  which  the  material  of  this  study  cannot  as 
yet  give  satisfactory  answer.  A  number  of  other  observ- 
ers, however,  have  reported  cases  of  the  paralysis  agi- 
tans type  in  which  complete  recovery  has  eventually 
occurred. 

The  infantile  type  of  the  disease  (Neonatorum)  seems 
to  afford  a  fair  outlook  as  far  as  the  acute  stage  of  the 
disease  is  concerned.  Such  patients  as  have  been  under 
observation  survived  the  acute  stage  of  the  disease.  On 
the  other  hand,  all  of  these  infants  are  still  in  a  precarious 
condition  since  they  suffer  from  the  effects  of  a  greatly 
impaired  central  nervous  system  which  imposes  a  handi- 
cap upon  them  in  meeting  their  somatic  and  visceral 
requirements. 

During  the  inception  of  the  acute  stage  of  all  cases 
of  epidemic  encephalitis  a  guarded  prognosis  seems  to 
be  indicated. 

Other  Types  of  Epidemic  Encephalitis.  A  review  of  the 
literature  makes  it  possible  to  recognize  types  of  this 
disease  other  than  those  which  have  come  under  the 
observation  of  the  writers;  and  while  it  is  not  yet  possible 
to  include  these  types  in  our  series,  they  seem  so  well 
established  in  the  experience  of  others,  as  to  necessitate 
their  inclusion  here  for  the  sake  of  completeness. 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS      65 

Among  these  are  types  which  have  been  described  as 
meningitic,  polyneuritic,  cerebellar  ataxic,  hemiplegic, 
diplegic  and  monoplegic.  These  varieties,  together  with 
those  already  mentioned  in  the  series  of  cases  under 
consideration,  call  attention  to  the  protean  character 
of  the  symptoms,  a  fact  which  accentuates  the  probability 
that  no  portion  of  the  nervous  system  is  exempt  from  the 
pathological  changes  of  the  disease. 

DIFFERENTIAL    DIAGNOSIS 

The  diagnosis  of  epidemic  encephalitis  is  not  without 
its  difficulties.  One  of  the  writers  was  recently  called  to 
see  a  case  of  so-called  "Sleeping  Sickness"  which  had 
all  of  the  clinical  features  of  a  typical  case  of  epidemic 
encephalitis,  even  including  the  negative  findings  of  the 
cerebrospinal  fluid.  Upon  post-mortem,  however,  the 
case  was  found  to  be  one  of  tuberculous  meningitis. 

In  another  instance,  a  case  which  had  acquired  con- 
siderable reputation  through  the  lay  press  as  Sleeping 
Sickness,  because  of  a  trance-like  state  which  had  per- 
sisted for  a  number  of  weeks,  finally  showed  a  positive 
Wassermann  reaction  in  the  spinal  fluid,  although  this 
test  had  on  several  previous  occasions  been  reported 
negative. 

Under  all  circumstances,  laboratory  findings  must  be 
evaluated  with  much  caution  and  always  with  particular 
reference  to  the  known  reliability  of  the  laboratory  from 
which  the  returns  are  received. 

Three  classes  of  disease  will  offer  some  perplexity  in 
the  differential  diagnosis. 

The  first  group  consists  of  diseases  in  which  the 
diagnosis  is  made  by  examination  of  the  spinal  fluid. 

1.  Tuberculous  meningitis  differs  from  epidemic  enceph- 
alitis in  that  the  spinal  fluid  is  usuall}'  under  increased 


66  EPIDEMIC    ENCEPHALITIS 

tension,  presents  a  pleocytosis  and  contains  the  tubercle 
bacillus. 

2.  Cerebrospinal  7nenvngitis  of  the  epidemic  type 
differs  from  epidemic  encephalitis  in  the  fact  that  the 
spinal  fluid  is  cloudy  or  flocculent,  contains  many  leu- 
cocytes, in  some  of  which  may  be  recognized  the  patho- 
genic organism  of  the  disease,  the  meningococcus. 

3.  Cerehrosjnnal  syphilis  differs  from  epidemic  en- 
cephalitis by  the  positive  Wassermann  reaction  in  the 
spinal  fluid,  a  marked  pleocytosis,  increased  globulin, 
and  either  a  paretic  or  a  luetic  colloidal  gold  curve. 

The  second  group  of  diseases  consists  of  those  whose 
recognition  will  be  aided  by  certain  pathological  tests. 

1.  Typhoid  fever,  the  nature  of  which  will  be  recog- 
nized by  the  Widal  reaction,  the  temperature  curve,  the 
enlarged  spleen  and  the  rose  spots. 

2.  Diphtheritic  paralysis,  whose  chief  differential 
feature  is  the  discovery  of  the  Klebs-I.oeffler  bacillus 
in  the  throat  and  a  history  of  suggestive  diphtheritic 
infection. 

3.  Uremia,  in  which  the  routine  tests  of  the  urine  show 
an  albuminurea  or  the  presence  of  renal  casts.  These 
findings  may  be  substantiated  by  an  estimation  of  the 
blood  urea  or  of  the  renal  efficiency  by  the  phenol- 
sulphonaphthalein  test. 

4.  Botulism.  This  condition  is  distinguished  by  the 
presence  of  the  bacillus  botulinus  in  the  food  par- 
taken by  the  patient  immediately  prior  to  the  on- 
set of  the  disease  and  by  the  acute  gastrointestinal 
disturbances. 

The  third  group  represents  conditions  which  may  be 
distinguished  by  their  clinical  features: 

1.  Hysteria,  is  recognized  chieifly  by  the  presence  of 
hysterical   stigmata,    the   absence   of   pyrexia   and   the 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS      07 

presence  of  marked  sensory  disorders,  such  as  hemian- 
aesthesia  or  a  contraction  of  the  visual  fields.  The  presence 
of  normal  reflexes  and  the  absence  of  true  palsies, 
nystagmus  and  other  oculomotor  disturbances  are  also 
significant. 

2.  Cerebral  tumor,  a  diagnosis  made  in  one  of  the 
twenty  cases  of  the  present  series,  may  be  differentiated 
by  the  absence  of  optic  atrophy,  papilledema,  vomiting 
and  paroxysmal  headache. 

3.  Acute  dementia  is  distinguished  by  the  persistence 
of  maniacal  delirium  unaccompanied  by  stupor  or 
pyrexia. 


CHAPTER  XII 


NATURE    OF   THE    DISEASE 


(Whether  this  is  a  new  disease  or  a  recent  outcropping 
of  an  old  epidemic  tendency  is  a  much  debated  subject. 
The  occurrence  of  prolonged  and  profound  sleep  in 
connection  with  epidemic  diseases  is  not  new  in  medical 
history.  Such  somnolence  has  been  described  in  connec- 
tion with  many  epidemics  of  influenza  since  the  earliest 
times.  Zuelzer^^  reports  the  fact  that  in  an  epidemic  of 
influenza  occurring  in  1712,  profound  sleep  was  so  fre- 
quent and  pronounced  a  symptom  that  in  Tubingen  the 
disease  came  to  be  known  as  the  Sleeping  Sickness.  In 
more  recent  times,  Longuet^^  in  1892  gives  an  account  of 
a  mysterious  disease  known  as  "Nona"  also  "Nonna." 
This  was  said  to  have  occurred  especially  in  northern 
Italy  and  Hungary  and  to  be  characterized  by  lethargy 
and  weakness.  The  derivation  of  the  word  "Nona" 
seems  to  be  obscure;  the  name  was  given  to  an  alleged 
new  form  of  disease  reported  in  1890  in  northern  Italy, 
Bavaria  and  Russia.  It  appears,  however,  that  there 
is  little  foundation  for  the  belief  that  there  is  such  a  new 
disease,  since  the  reports  seem  to  be  founded  on  cases  of 
typhoid  fever  with  coma  or  of  somnolence  following 
influenza  as  well  as  of  smallpox  of  an  irregular  and  severe 
form.  A  recent  epidemic  of  lethargic  encephalitis  in 
Vienna  was  described  by  Economo  in  1917,  while  Netter 
reported  a  similar  outbreak  in  Paris  in  1918.  The  report 
of    an    inquiiy   into    an    obscure    disease,    Encephalitis 

68 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS      69 

Leihargica,  made  by  a  commission  in  London,  in  1918, 
records  the  occurrence  of  168  cases,  together  with  a 
valuable  analysis  of  this  material,  Wilson,  Hall  and  others 
have  also  made  records  of  a  number  of  cases  of  this 
disease  during  the  same  period  in  London. 

In  the  latter  part  of  1918  and  early  1919  the  first  cases 
appeared  in  America,  and  as  had  previously  happened 
in  England  and  France,  it  was  several  months  before 
there  was  general  recognition  of  the  exact  nature  of  the 
"sleeping  sickness"  we  were  observing. 

In  all  probability,  this  is  not  a  new  disease,  but  an 
epidemic  whose  presence  has  attracted  more  wide- 
spread recognition  and  more  careful  analysis  than  in  the 
past. 

/^Epidemiologically,  it  must  be  regarded  as  an  infectious 
disease,  probably  communicable.  This,  at  least,  is  the 
attitude  taken  at  present  by  the  English  authorities, 
for  the  disease  has  been  made  temporarily  a  notifiable 
one  in  England  and  Wales  for  the  period  of  one  year. 

The  bacteriological  evidence  thus  far  adduced  does  not 
throw  much  light  upon  the  pathogenesis  of  epidemic 
encephalitis.  Von  Wiesner,  '^  studying  one  of  Economo's 
cases,  isolated  a  gram  positive  diplostreptococcus  in 
1917.  This  he  was  able  to  cultivate  and  the  culture  of  it 
injected  in  a  macacus  rhesus  produced  somnolence  with 
muscular  weakness,  while  peritoneal  injection  into  guinea 
pigs  caused  death  from  internal  hemorrhage.  A  filtrate 
from  the  original  brain-cord  emulsion  of  the  patient 
through  a  Berkfeldt  filter  injected  into  a  macacus  rhesus 
produced  no  symptoms,  although  an  unfiltered  emulsion 
of  the  brain  and  spinal  cord  injected  subdurally  into  the 
same  species  caused  death  in  forty-six  hours,  the  animal 
having  previously  presented  profound  stupor  in  addition 
to  a  paresis  of  the  right  hind  leg. 


70  EPIDEMIC    ENCEPHALITIS 

Mcintosh^*  examined  two  cases  and  found  in  one  a 
gram  positive  motile  nonproteolytic  anaerobic  bacillus 
which  resembled  the  vibrion  septique  of  Pasteur.  In 
the  other  case,  there  was  a  gram  positive  non-motile 
anaerobic  bacillus  which  belonged  to  the  bacillus  Welchii 
group  of  anaerobes.  He  found  no  bacillus  botulinus  and 
no  pleomorphic  coccus  such  as  described  by  Rosenow^^ 
in  acute  anterior  poliomyelitis.  Mcintosh  injected 
emulsions  of  the  basal  ganglia,  pons,  medulla  and  cervical 
cord  intracerebrally  and  intraperitoneally  in  macacus 
rhesus  but  produced  no  results.  In  this  respect,  his  find- 
ings are  in  direct  contradiction  to  those  of  von  Wiesner. 

Cultures  from  the  blood  and  spinal  fluid  were  sterile, 
as  were  also  those  taken  from  the  excreta  of  the  naso- 
pharynx and  from  the  feces. 

Sera  of  recovered  patients  injected  into  mice  did  not 
protect  these  animals  against  injections  of  botulinus 
toxin.  MacNalty^^  suggests  that  epidemiologically,  clinic- 
ally, and  pathologically,  epidemic  encephalitis  differs 
from  classical  poliomyelitis  and  is,  in  fact,  a  disease 
sui  generis.  MacNaltj^  suggests  that  the  relation  of 
epidemic  encephalitis  to  poliomyelitis  may  possibly  be 
that  of  typhoid  fever  to  paratyphoid. 

The  pathological  study  of  a  number  of  cases  establishes 
the  fact  that  the  tissue  reaction  due  to  the  infection  is  an 
actual  inflammation.  Marinesco^^  has  pointed  out  that 
epidemic  encephalitis  may  be  differentiated  from  the 
changes  of  botulism  and  the  alcoholic  polioencephalitis 
of  Wernicke  by  the  fact  that  in  these  latter  diseases  the 
changes  are  not  those  of  a  true  inflammation  but  rather 
due  to  profound  alterations  in  the  vessel  walls,  leading  to 
secondary  degenerative  processes  in  the  nerve  tissue.  He 
also  calls  attention  to  the  fact  that  although  the  true 
sleeping  sickness   may  resemble   epidemic   encephalitis 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS      71 

in  many  respects,  its  differentiation  depends  upon  dis- 
covery of  the  trypanosoina  gambiensc. 

Marinesco  and  Mcintosh  both  allude  to  what  they 
deem  essential  pathological  differences  between  acute 
anterior  poliomyelitis  and  epidemic  encephalitis. 

In  poliomyelitis,  for  instance,  the  distribution  of  the 
lesion  is  largely  confined  to  the  cord.  The  pia-arachnoid, 
as  a  rule,  shows  considerable  involvement,  while  the 
changes  in  the  brain  are  slight. 

In  encephalitis,  however,  the  greatest  changes  are  in 
the  basal  ganglia  and  nuclei  of  the  brain  stem,  the  gray 
matter  of  the  floor  of  the  fourth  ventricle  and  around  the 
aqueduct  of  Sylvius.  The  pia-arachnoid  is  but  little 
involved  and  changes  in  the  spinal  cord  are  rare. 

The  character  of  the  cellular  infiltration  in  the  two 
diseases  is  also  a  distinguishing  feature.  In  poliomyelitis, 
polymorphonuclear  leucocytes  predominate  and  plasma 
cells  are  of  less  frequent  occurrence.  Hemorrhages  are 
common  and  relatively  large,  while  the  vascular  changes 
affect  the  smaller  arteries. 

In  encephalitis,  plasma  cells  are  much  more  common, 
while  the  polymorphonuclear  cells  are  rare.  Hemorrhages 
when  present  are  usually  microscopic.  The  infiltration 
is  adventitial  about  the  small  vessels  and  more  especially 
the  venules. 

The  cellular  changes  in  the  two  diseases  are  somewhat 
different.  In  poliomyelitis,  degenerations  are  pronounced 
and  neuronophagia  is  active,  while  in  encephalitis  the 
cells  are  not  much  involved ;  such  changes  as  do  occur  are 
relatively  mild  and  neuronophagia  when  present  is  not 
marked. 

The  clinical  differences  between  poliomyelitis  and 
epidemic  encephalitis  have  been  emphasized  by  Wilson 
and  MacNalty. 


72  EPIDEMIC    ENCEPHALITIS 

It  seems  justifiable  to  conclude,  therefore,  from  ana- 
tomical, clinical,  pathological  and  bacteriological  evi- 
dence, that  these  two  diseases  are  not  identical,  although 
they  may  be  closely  allied  in  their  pathogenesis. 

Draper  ^2  thinks  epidemic  encephalitis  is  strikingly 
like  poliomyelitis  in  many  respects,  and  may  be  a  sub- 
group of  the  latter.  He  is  of  the  opinion  that  animal 
experimentation  alone,  carried  on  upon  a  large  scale, 
can  give  the  solution  to  this  problem. 

Much  has  been  written  concerning  the  relation  of 
epidemic  encephalitis  to  influenza.  Many  hints  from  the 
past  and  not  a  few  confident  assertions  in  the  present 
aim  to  give  these  two  diseases  a  single  identity.  There 
seems,  however,  little  real  basis  for  this  position;  but 
the  question  probably  cannot  be  definitely  decided  until 
more  is  known  concerning  the  exact  pathogenesis  of  each 
of  these  clinical  conditions. 

In  the  series  of  cases  described  by  the  writers,  fifty 
per  cent  of  the  patients  gave  no  history  indicative  in  any 
way  of  influenza,  unless  it  be  conceded  that  the  abrupt 
onset  of  cerebral  symptoms  without  the  occurrence  of 
any  of  the  more  usual  symptoms  of  influenza  were  an 
expression  of  this  latter  disease.  It  is  not  unlikely  that 
the  relation  between  these  two  diseases  may  be  a  mutu- 
alistic  symbiosis,  or  that  one  may  be  metabiotic  to  the 
other. 


CHAPTER  XIII 


TREATMENT 


No  specific  agent  or  remedj^  has  yd  been  discovered 
in  the  way  of  serum  or  vaccine  for  deahng  directly  with 
the  disease  or  affording  immunity  against  it. 
(^During  the  acute  stage  in  all  types  of  epidemic  en- 
cephalitis, the  patient  should  be  kept  in  bed  and,  since 
this  is  proba])ly  a  communicable  disease,  some  degree  of 
isolation  should  be  established.  Perhaps  the  barrier  sys- 
tem or  one  in  which  nurse  and  patient  are  kept  apart 
from  the  rest  of  the  household,  will  suffice.  All  l^edding, 
cloths,  utensils,  etc.,  which  come  in  direct  contact  with 
the  patient,  should  be  properly  sterilized^ 
(The  principle  of  treatment  is  essentialh'  sjmiptomatic. 

For  pyrexia,  cold  sponges  or  a  light  cold  pack  when  the 
fever  is  102  or  over  usually  give  the  best  results. 

Urotropine,  10  grains  three  times  a  day,  is  theoretically 
presumed  to  be  of  benefit  and  may  be  used  in  this  amount 
or  in  increasing  doses. 

Elimination  is  an  important  feature  in  the  treatment; 
the  bowels  and  kidneys  should  be  kept  active  and  flushed 
out  as  much  as  possible.  For  this  latter  purpose,  high 
colonic  irrigations  of  normal  salt  solutions  should  be 
given  daily,  or  if  this  proves  fatiguing  to  the  patient,  two 
or  three  times  a  week.  As  much  water  as  possible  should 
be  administered  bj^  mouth,  and  when  this  becomes  diffi- 
cult, the  continuous  Murphy  drip  is  advisable. 

Feeding  should  be  careful  throughout  this  period  and 

73 


74  EPIDEMIC    ENCEPHALITIS 

limited  to  a  fluid  diet.  Frequent  feedings  of  two  to  four 
ounces  every  two  hours  are  preferable  to  larger  quanti- 
ties at  longer  intervals.  Unless  otherwise  indicated,  the 
diet  need  not  carry  more  than  a  medium  calorie  value 
and  only  in  cases  where  emaciation  is  marked  and  rapid 
is  forced  feeding  necessary. 

Repeated  lumbar  puncture  has  been  advantageous  in 
some  cases,  10  to  20  c.c.  of  the  fluid  being  withdrawn 
every  three  to  five  days. 

In  the  more  profoundly  lethargic  and  cataleptic  cases, 
care  should  be  taken  of  the  skin  to  prevent  decubitus, 
and  when  indicated,  cardiac  stimulants,  such  as  digipura- 
tum  and  digalin,  should  be  administered. 

Restlessness  is  frequently  a  difficult  complication. 
This  seems  to  be  best  treated  by  means  of  the  bromides, 
the  usual  combination  of  ammonium  and  sodium  of 
potassium  giving  good  results,  in  doses  of  10  grains  each, 
well  diluted,  three  times  a  day. 

For  insomnia,  10  grains  of  medinol  dissolved  in  warm 
milk,  or  3  grains  of  allyl  barbituric  acid  similarly  ad- 
ministered at  bedtime,  usually  produce  sleep.  For  some 
patients,  however,  other  similar  remedies  may  be  re- 
quired, since  those  mentioned  may  not  be  as  eifective  as 
certain  other  soporifics. 

For  active  or  violent  delirium,  the  most  efficient 
remedy  is  paraldehyde  in  doses  of  4  drams  every  four 
hours  if  indicated.  In  certain  cases,  however,  as  for  exam- 
ple those  in  which  the  maniacal  tendency  is  most  devel- 
oped, the  prolonged  warm  bath  gives  excellent  results. 
This,  however,  should  not  be  attempted  by  inexperienced 
attendants  and  should  be  under  the  direct  supervision 
of  the  attending  physician.  In  cases  showing  violence  or 
active  delirium,  restraint  should  be  avoided  as  much  as 
possible.  It  is  much  less  exhausting  to  the  patient  if  he 


CLINICAL  AND  PATHOLOGICAL  MANIFESTATIONS      75 

be  permitted  to  carry  out,  in  part  at  least,  the  more  or 
less  indefinite  purposes  arising  from  the  activity  due  to  his 
delirium.  If  circumstances  will  permit,  it  is  better  not  to 
attempt  to  restrain  the  patient  in  bed,  but  allow  him 
some  latitude,  while  surrounding  him  with  the  necessary 
protection  against  injuring  himself  or  others. 

For  the  tremor,  either  of  the  agitans  type  or  the  more 
rapid  oscillation,  a  prescription  containing  hyoscine 
hydrobTomate,  gr.  Mso  with  codeine  sulphate  }4  gr- 
may  be  given  three  times  a  day.  For  these  cases,  mor- 
phine is  best  avoided,  and  the  bromides,  if  used  at  all, 
should  be  administered  in  small  doses,  that  is,  not 
exceeding  30  gr.  a  day. 

During  the  stage  of  convalescence,  care  should  be 
exercised  in  not  permitting  the  patient  to  get  up  and 
about  too  early.  This  error  frequently  leads  to  relapses 
and  unnecessarily  prolongs  the  asthenia  consequent 
upon  the  disease.  A  partial  rest-cure  plan  should  be 
adopted  when  the  patient  is  first  attempting  to  get 
about.  This  should  never  be  left  to  the  discretion  of  the 
patient,  but  prescribed  in  detail,  according  to  the  hours 
of  rest  required,  the  amount  of  exercise  or  engagement  in 
usual  occupation  and  such  other  directions  as  seem 
necessary.  During  this  time  a  simple  nutritious  diet  and 
plenty  of  water  are  essential/) 

For  the  asthenia  seen  so  frequently  in  these  patients, 
an  excellent  remedy  is  suprarenal  residue,  5  minims, 
three  times  a  day  after  each  meal.  This  may  be  best 
administered  by  mouth  in  combination  with  the  hypoder- 
mic injection  of  cacodylate  strychnia,  gr.  3go  ^very  daj^ 
either  with  or  without  the  arsenate  of  iron. 

During  the  stage  of  after-care  of  the  palsy,  especially 
the  facial  paralysis,  much  benefit  may  be  had  from  daily 
facial    massage    and    the    application    of    the    galvanic 


7G  EPIDEMIC    ENCEPHALITIS 

sinusoidal  current  in  mild  strength  directly  over  the 
facial  nerve  for  fifteen  minutes  three  times  a  week. 
The  faradic  current  is  of  little  use,  especially  in  the 
early  stages  of  the  paralysis,  when  faradic  response 
is  generally  absent. 


PART  II 

CLINICAL  AND  PATHOLOGICAL  STUDIES  OF- 
SELECTED  CASES 


CHAPTER  XIV 

ETIOLOGICAL    FACTORS    AND    CLASSIFICATION 

A  ge.  No  age  seems  to  be  exempt,  but  the  greater  pro- 
portion of  eases  are  in  young  adults.  The  age  incidence 
in  the  different  decades  in  161  cases  selected  from  the 
literature  are  as  follows: 

Under  1  year 3 

1  to  10  years 29 

10  to  20  years 29 

20  to  30  years 33 

30  to  40  years 22 

40  to  50  years 21 

50  to  60  years 17 

60  to  70  years 7 

Sex.  The  sexes  are  about  equally  affected,  but  as  in 
poliomyelitis  there  may  be  a  slight  preponderance  of 
males.  NeaP"  reports  33  males  in  40  cases.  In  99  cases 
reported  from  civil  practice,  50  were  males  and  49 
females. 

Relation  to  Influenza.  The  relation  of  this  disease  to 
influenza  has  given  rise  to  considerable  discussion  in 
this  country.  A  large  proportion  of  cases  reported  here 
had  suffered  from  influenza  at  i3eriods  varying  from  one 
week  to  six  months  previously.  Occasionally  encephalitis 
has  followed  immediately  what  was  supposed  to  be 
influenza  and  some  authors  have  considered  it  influ- 
enzal encephalitis.  There  has  been  little  reference  to 
the  relation  of  these  diseases  in  the  foreign  literature 
until  very  latelj^  as  the  epidemic  of  encephalitis  ante- 

79 


80  EPIDEMIC    ENCEPHALITIS 

dated  that  of  influenza  in  both  France  and  England. 
There  seems  to  be  but  shght  logical  ground  for  consider- 
ing these  two  conditions  as  having  any  active  relation 
to  each  other.  As  is  stated  in  the  description  of  the  symp- 
toms of  onset,  they  are  very  similar  to  and  are  frequently 
mistaken  for  those  of  influenza. 

Relation  to  Poliomyelitis.  Its  relation  to  anterior  polio- 
myelitis is  not  easy  to  prove  or  disprove.  They  both  seem 
to  be  systemic  diseases  the  virus  of  which  is  probably 
lymph  borne,  and  has  a  special  affinity  for  the  motor  ele- 
ment of  the  central  nervous  system. 

The  geographical  distribution  of  the  epidemic  of  en- 
cephalitis has  been  far  more  widespread  than  that  of 
any  epidemic  of  poliomyelitis,  but  it  has  not  been  so 
severe  in  any  one  small  area. 

The  method  of  transmission  of  epidemic  encephalitis 
and  poliomyelitis  is  absolutely  obscure.  There  is  growing 
opinion  that  direct  contagion  is  not  the  mode  of  trans- 
mission of  poliomj'^elitis,  and  there  seems  to  be  no  evi- 
dence of  contagion  in  the  spread  of  epidemic  encephalitis. 
Both  French  and  British  authors  have  observed  that  two 
cases  have  never  developed  in  the  same  house.  It  seems 
not  unlikely,  however,  that  the  virus  producing  both  of 
these  diseases  is  similar,  but  of  different  strain. 

Epidemic  encephalitis  presents  certain  differences  from 
poliomeylitis  which  cannot  be  overlooked: 

It  affects  all  ages,  but  more  especially  young  adults. 

The  palsies  are  usually  less  profound,  may  be  variable 
and  have  more  of  a  tendency  to  clear  up. 

The  localization  is  in  the  brain  and  brain  stem  rather 
than  in  the  cord. 

The  pathological  changes  are  less  severe :  there  is  less 
evidence  of  meningeal  inflammation;  more  of  a  tendency 
to  hemorrhage;  less  severe  inflammatory  and  degenera- 


STUDIES  OF  SELECTED  CASES         81 

tive  changes    in    the    nerve    cells,    and    less    marked 
neuronophag^^ 

Possibly  the  greatest  difference  between  the  two  con- 
ditions is  in  the  nature  of  the  action  of  the  virus  on  the 
nerve  elements.  In  poliomyelitis  there  is  a  sudden,  sharp 
attack  which  develops  rapidly  and  in  a  few  days  attains 
the  maximum  of  severity,  quickly  producing  the  greatest 
extent  of  destruction.  In  epidemic  encephalitis  the  onset 
is  frequently  very  gradual  and  the  progress  of  the  disease 
slow,  in  some  instances  requiring  several  months  to  reach 
its  greatest  severity,  and  even  then  the  findings  have  a 
tendency  to  variability,  being  subject  to  exacerbations 
and  remissions. 

CLASSIFICATION    OF    ANATOMICAL   TYPES 

While  no  hard  and  fast  classification  can  be  made  and 
none  is  necessary,  still  it  may  have  some  value  in  that 
the  various  forms  not  only  have  different  symptoms,  but 
also  frequently  have  a  different  course  and  prognosis. 
In  making  a  classification  it  is  desirable  to  use  as  nearly 
as  possible  an  anatomic  basis.  As  a  result  of  studying 
the  cases  described  in  the  literature  as  well  as  those 
personally  observed,  I  believe  that  most  of  them  maj'  be 
placed  in  one  of  the  following  groups: 

1.  Cases  with  general  symptoms  indicating  involve- 
ment of  the  nervous  sj'stem,  but  absent,  scant  or  fleeting 
localizing  signs. 

2.  Meningitic  type. 

3.  Cortical  tj'pe. 

4.  Pyramidal  system  type. 

5.  Thalamic  type. 

6.  Corpus  striatum  (extra-pyramidal)  type. 

7.  Brain  stem  type. 


82  EPIDEMIC    ENCEPHALITIS 

8.  Cerebellar  type. 

9.  Spinal  type. 

10.  Peripheral  nerve  type. 

11.  Multiple  diffuse  lesion  type. 

As  in  poliomyelitis,  there  is  also  an  abortive  form,  but 
it  does  not  comprise  a  distinct  group,  as  abortive  cases 
may  occur  in  many  of  the  above  types. 

GENERAL    OUTLINE    OF   VARIOUS    FORMS 

1.  Cases  with  General  Sijmptoms.  The  cases  in- 
cluded in  this  group  frequently  present  in  the 
early  stages  signs  of  cerebral  irritation,  restlessness, 
delirium,  possibly  hallucinations  and  delusions;  later 
lethargy,  stupor,  and  general  muscular  rigidity  super- 

.  vene.  There  is  usually  fever  at  the  onset  and  at  the  end 
if  the  termination  is  fatal.  The  predominating  features 
are  the  lethargy  and  stupor  or  coma,  though  there 
may  be  slight  or  fleeting  evidences  of  cranial  nerve 
involvement. 

2.  Meningitic  Type.  The  meningitic  form  is  charac- 
terized by  the  prominence  of  manifestations  of  menin- 
geal irritation,  fever,  headache,  stiffness  of  the  neck  and 
a  slight  Kernig  sign. 

3.  Cortical  Type.  I  have  not  observed  or  seen  reported 
any  cases  where  findings  due  to  cortical  lesions  predomi- 
nated, but  isolated  monoplegias  and  aphasias  pointing 
to  cortical  localization  are  present,  usually,  however, 
in  the  type  where  the  general  symptoms  dominate  the 
clinical  picture. 

4.  Pyramidal  System  Type.  In  this  type  signs  of 
pyramidal  tract  disturbances  are  present.  The  onset 
may  be  a  sudden  hemiplegia.     Later  evidences  of  other 


STUDIES  OF  SELECTED  CASES         83 

lesions  appear,   especially  those  involving  the   cranial 
nerve  nuclei. 

5.  Thalamic  Type.  There  are  no  cases  reported  which 
show  the  typical  thalamic  syndrome;  but  ataxia  and 
choreo-athetoid  movements  associated  with  lesions  of 
structures  in  close  proximity  with  the  optic  thalamus, 
point  to  thalamic  involvement. 

6.  Corpus  Striatum  Type.  Here  are  placed  cases  show- 
ing a  more  -or  less  typical  Parkinsonian  syndrome.  Gen- 
eral muscular  rigidity  with  irregular  cogwheel  release  on 
passive  movement,  characteristic  tremor,  mask-like  ex- 
pressionless facies,  bowed,  rigid  attitudes  and  festinating 
gait. 

7.  Brain  Stem  Type.  Involvement  of  some  of  the 
cranial  nerves  occurs  in  the  greater  proportion  of  cases 
of  epidemic  encephalitis.  This  group  is  limited  to  those 
showing  the  cranial  nerve  palsies  as  the  principal  feature. 

8.  Cerebellar  Type.  Cases  where  ataxia  is  the  principal 
finding  have  been  noted,  but  have  not  been  clearly  and 
thoroughly  described. 

9.  Spinal  Type.  Signs  of  involvement  of  the  anterior 
horn  cells  are  frequently  present.  Cases  presenting  mainly 
this  feature  are  described  under  the  captions  "anterior 
and  posterior  poliomyelitic  types"  (p.  45). 

10.  Peripheral  Nerve  Type.  Involvement  of  the  peri- 
pheral nerves  is  rare.  A  musculo-spiral  palsy  was  observed 
in  Case  XX  reported  on  page  55. 

11.  Multiple  Diffuse  Lesion  Type.  In  this  type  the 
lesions  are  scattered  profusely  throughout  the  brain 
and  cord.  The  cases  included  in  this  group  show  evidences 
of  multiple  localizing  lesions  but  without  predominating 
features  which  place  them  in  any  of  the  other  groups. 
They   may   l)e   clinically   similar  to   multiple  sclerosis. 


84  EPIDEMIC    ENCEPHALITIS 

In  116  cases  sufficiently  completely  reported  to  allow 
of  classification,  the  grouping  is  as  follows : 

General  type 28  cases 

Meningitic  type 7  cases 

Pyramidal  system  type 5  cases 

Thalamic  type 1  case 

Corpus  striatum  type 14  cases 

Brain  stem  type ■  •  •  ■  45  cases 

Spinal  type 2  cases 

Peripheral  nerve  type 1  case 

Diffuse  multiple  type 13  cases 


CHAPTER  XV 


PATHOLOGICAL    CHANGES 


Macroscopic.  On  the  surface  of  the  brain  there  may 
be  no  macroscopic  changes  except  for  a  shght  degree  of 
vascular  congestion  over  the  cortex.  Frequently  there  is 
frank  congestion  and  a  slight  degree  of  meningitis  which 
appears  in  scattered,  irregular  patches  over  the  cortex  or 
base.  There  may  be  small  hemorrhages  from  the  surface 
vessels  between  the  layers  of  the  pia.  In  the  areas  where 
there  is  meningeal  inflammation  the  pia  is  thickened, 
less  transparent,  and  of  a  grayish-red  color.  Tliis  appear- 
ance is  observed  most  frequently  on  the  base  of  the  brain 
in  the  neighborhood  of  the  peduncles  and  in  the  inter- 
peduncular space.  On  section  of  the  brain  substance  there 
are  tinj^  red  specks  or  streaks  which  may  be  diffusely 
scattered  throughout  the  cerebral  cortex,  basal  ganglia, 
cerebellum  or  brain  stem.  As  a  rule  they  are  most  promi- 
nent in  the  subthalamic  region,  the  cerebral  peduncles 
and  in  the  pons.  They  are  scattered  promiscuously 
throughout  the  gray  and  white  matter  and  may  be  due 
to  small  capillary  hemorrhages;  but  on  close  examination 
many  of  them  will  be  seen  to  be  simply  small  vessels 
distended  with  blood.  Throughout  both  brain  and  cord 
the  congestion  is  more  marked  in  the  gray  than  in  the 
white  matter.  In  the  brain  stem  the  hemorrhages  may 
be  of  larger  size  and  at  times  are  several  millimeters  in 
diameter.  In  the  severe  cases  without  pronounced  local- 
izing signs  minute  punctate  hemorrhages  have  been 
found  profusely  scattered  in  the  gray  and  white  matter  of 

85 


86 


EPIDEMIC    ENCEPHALITIS 


the  cerebrum,  cerebellum,  pons  and  medulla,  but  with- 
out particular  localization  anywhere. 

Microscopic.  Changes  are  found  both  in  tissues  of 
mesodermogenic  and  of  ectodermogenic  origin.  The  pia 
mater  in  most  areas  is  normal.  Where  it  is  involved  it  is 


■-■■ '-^t'  ■-.►-;'■*■-■■  :--%/i.;^V  ■  — .r.  ^■i     - 


A:"  ■'^^'  ^■l■■' 


Fig.   7.— Thalamus.      Diffuse   Crllular    1  nliltiation. 

thickened,  its  laj^ers  being  separated  by  edema,  cellular 
infiltration,  and  at  times  red  blood  cells  which  have  es- 
caped from  the  pial  capillaries.  In  the  substance  of  the 
brain  there  is  diffuse  capillary  congestion  which  is  most 
marked  in  the  involved  areas.  The  Virchow-Robin  spaces 


STUDIES  OF  SELECTED  CASES 


87 


1'  ^ 


^  ■»■■ 


■%    #' 


■'  ■     *  •  -  ■'  ?*■ 


A   ■ 


■  •■<  .  '*^'  ■<  -^  • ', ' 

i'lii.   >. —  I  naiaimis.      i'loudy   iSwollinu;  m    .\curuc\i('s. 


88 


EPIDEMIC    ENCEPHALITIS 


of  the  vessel  wall  may  contain  red  blood  cells  but  more 
frequently  show  moderate  distension  with  lymphocytes. 
Occasionally  polymorphonuclear  leucocytes  are  seen 
in  the  adventitial  lymph  spaces,  but  almost  all  of  the 
cells  are  similar  to  the  lymphocytes  of  the  blood.  The 


Fig.  9. — Thalamus.     Acute  Cloudv  Swelliuii;  of  Xerve  Cells. 


hemorrhages  are  frequently  perivascular,  that  is,  largely 
confined  to  the  perivascular  space  of  His.  Some  of  them 
are  larger,  irregularly  infiltrating  the  surrounding  tissue. 
In  some  areas  small  collections  of  cells  are  seen  which  may 
be  in  either  the  gray  or  white  matter  and  have  no  appar- 


STUDIES  OF  SELECTED  CASES 


89 


Fig.   10. — Thalamus.     Higher    Magnification.     Severe  Degenera- 
tive Changes  and  Neuronophagy  in  Some  of  the  Nerve  Cells. 


90  EPIDEMIC    ENCEPHALITIS 

ent  relation  to  a  nerve  cell  or  blood  vessel.  The  cells 
forming  these  accumulations  are  largely  ameboid  glia 
cells,  though  in  some  areas  lymphocytes  are  occasionally 
seen.  Usually  very  few  of  the  blood  vessels  show  any 
infiltration  of  the  adventitial  lymph  space,  and  unless 

'i^i^  V'-'^  ■••';^v -v'is,  v.-i»^-,    .w  -'  --:r'i'-''-  ':~-^^:'":^-.r 

>:*-''-i    ',  ',    ;      -'-     -        »_  "w»      ■"  ■"■■,"-    '  -     '      .   T  .    -^  .-"^. "". -v.  .     :  ''"  ' 

.':■■■     ^    ■:'<■"  jiJ     -  -■  .  .'^  -^  -■_'     ,  »,.^'-r'        -.1  -     . 


^- 


''l'->I^:^-'-:'"-->'''SS^ 

I^!^--^^*/  ':'■-'::■''■'--•'' 

Fig.   11. — Capillary  Congestion  in  Internal  Capsule  Bordering  on 
Thalamus. 

sections  from  many  portions  of  the  brain  are  examined, 
it  may  not  be  found. 

The  alterations  in  the  ectodermogenic  or  true  nervous 
tissue  are  not  as  marked  as  in  anterior  poliomyelitis. 
The  milder  grades  of  acute  cloudy  swelling  are  found 


STUDIES  OF  SELECTED  CASES         91 

in  some  of  the  motor  cells  of  the  ponto-medullary  nuclei. 
The  nerve  cells,  except  in  the  immediate  neighborhood 
of  inflammatory  areas,  however,  frequently  appear 
surprisingly  normal,  showing  no  evidence  of  chroma- 
tolysis  or  acute  cloudy  swelling.  At  times  there  is  mode- 
rate neuronophagia,  but  it  never  seems  to  be  marked  and 
is  frequently  absent.  The  changes  in  the  nerve  cells 
show  sharp  contrast  with  those  found  in  acute  anterior 
poliomyelitis,  where  very  severe  grades  of  all  variations 
of  cell  disintegration  and  destruction  are  seen.  Marincsco 
observed  cytolysis  of  the  cells  in  the  locus  niger  with  the 
liberation  of  the  melanic  pigment,  which  was  picked  up 
by  the  neighboring  phagocytes.  Moderate  degrees  of 
acute  cloudy  swelling  are  found  in  the  neuronocytes 
of  the  cortex,  basal  ganglia,  brain  stem  and  cord.  There 
is  solution  of  the  tigroid  substance,  the  cells  are  swollen, 
the  nuclei  eccentric,  and  occasionally  there  is  satel- 
litosis  and  rarely  neuronophagia.  Vacuolization,  ruptm-e 
of  the  cell  membrane,  and  complete  dissolution  of  the 
cell  body  with  active  pai-tioipatioii  of  phagocyte  cells, 
are  uncommon. 


CHAPTER  XVI 


SYMPTOMATOLOGY 


The  onset  of  the  illness  may  be  sudden,  but  the  char- 
acteristic symptoms  frequently  do  not  appear  for  several 
days  after  the  initial  disturbance.  Slight  nasal  discharge, 
headache,  dizziness,  generalized  pain  and  aching,  fever 
and  sweating,  often  lead  the  physician  to  believe  that 
the  patient  is  suffering  from  influenza.  A  day  or  two 
later  there  is  restlessness,  loss  of  appetite,  constipation, 
often  vomiting,  and  possibly  delirium  at  night.  After 
a  period  varying  from  two  or  three  to  fourteen  days,  the 
symptoms  gradually  subside  and  an  abnormal  drowsi- 
ness ensues.  In  another  week  the  drowsiness  has  passed 
into  lethargy  or  stupor,  and  the  headache,  vomiting 
and  fever  usually  disappear.  Ptosis  or  other  evidences  of 
cranial  nerve  palsies  then  appear  as  well  as  other  signs 
of  general  or  localized  involvement  of  the  nervous 
system. 

While  this  description  of  the  early  symptoms  is  a  com- 
mon one,  at  other  times  there  may  be  no  general  pro- 
dromata.  Drowsiness  and  listlessness  may  appear  at 
first,  while  occasionally  diplopia,  ptosis  or  facial  weakness 
are  found.  Rarely  there  are  no  evidences  of  a  constitu- 
tional disorder,  but  there  suddenly  appears  a  hemi- 
plegia or  other  manifestation  of  a  serious  injury  to  the 
central  nervous  system.  At  times  the  picture  is  similar 
to  that  of  meningitis;  headache,  hyperaesthesia,  fever, 
stiff  neck  and  an  indefinite  Kernig  sign  are  found. 
Occasionally  the  onset  may  be  so  insidious  that  it  is 

92 


STUDIES  OF  SELECTED  CASES 


93 


impossible  to  determine  the  date  of  the  first  symptoms. 
Several  weeks  may  intervene  before  the  patient  con- 
siders his  complaint  of  enough  importance  to  consult  a 
physician.  Gradual  progressive  weakness  with  possibly 
slight  dizziness  and  headache  may  be  the  onlj^  symptoms 


Fig.   12. — Internal  Capsule.     Capillary  Congestion  and  Character 
of  Invading  Cells. 

for  several  weeks.  In  the  greater  proportion  of  cases 
there  is  more  or  less  marked  muscular  hypertonia  and  the 
whole  body  becomes  rigid.  All  the  active  movements 
are  slow,  difficult,  and  often  accompanied  by  a  rather 
coarse  tremor.   Wax-like  rigidity  or  catatonia  is  fre- 


94  EPIDEMIC    ENCEPHALITIS 

quently  present,  especially  in  the  early  part  of  the  lethargic 
stage.  Later  the  muscular  rigidity  may  be  as  pronounced, 
but  there  is  so  great  muscular  weakness  that  the  limbs 
cannot  be  maintained  in  any  position  which  requires 
muscular  effort.  Passive  motion  elicits  an  irregular  release 
or  cogwheel  resistance.  In  some  patients  peculiar  positions 
are  almost  constantly  maintained,  as  was  evident  in  Case 
VI  and  Case  X  of  Part  II.  This  condition  has  been  noted 
in  patients  presenting  peculiar  stereotyped  movements. 
These  movements  have  been  described  as  choreo-athetoid, 
but  possibly  are  more  of  a  major  tic.  They  consist 
in  the  constant  repetition  of  a  succession  of  move- 
ments or  gestures  involving  one  or  moi-e  entire  member 
of  the  body.  These  movements  cease  during  sleep,  are 
increased  by  emotional  excitement,  and  may  be  in- 
hibited or  stopped  for  a  short  time  by  voluntary  effort, 
but  are  otherwise  constantly  present.  The  localiza- 
tion of  a  lesion  producing  a  movement  of  this  character 
is  difficult.  It  may  possibly  originate  in  lesions  of  the 
optic  thalamus  with  irritation  of  the  extra  pj'ramidal 
motor  apparatus;  but,  on  the  other  hand,  it  seems  difficult 
to  believe  that  these  coordinated  and  synergic  move- 
ments could  be  initiated  outside  of  the  cerebral  cortex. 
Uncontrollable  laughter  or  smiling  is  sometimes  present 
(Case  IV)  and  maj^  cause  distress  to  the  patient.  Speech 
almost  constantly  shows  some  alteration.  It  is  frequentlj- 
weak,  possibly  little  more  than  a  whisper,  being  high- 
pitched,  slow  and  monotonous.  In  the  bulbar  cases 
various  degrees  of  dysarthria  are  present.  Some  patients 
are  unable  to  speak  or  utter  a  sound,  though  they  show 
no  evidence  of  paral3^sis  of  the  peripheral  mechanism 
of  speech  and  are  able  to  show  in  some  way  that  they 
are  conscious  and  have  normal  understanding.  In  other 
words  there  is  a  motor  aphasia. 


STUDIES  OF  SELECTED  CASES         95 

There  are  certain  other  findings  that  are  probably  pro- 
duced by  cortical  lesions.  These  are  spastic  monoplegias 
which  are  frequently  preceded  by  pain  and  hyper- 
sesthesia.  One  patient  observed  at  the  Presbj'terian 
Hospital,  and  reported  in  Part  I  (p.  20),  had  as  her 


Fig.   13. — Accumulation  of  Ameboid  Glia  Cells  in  the  Internal 

Capsule. 

initial  symptom  pain  in  the  index  finger  of  the  right 
hand,  which  rapidly  spread  to  the  whole  arm,  and  on 
disappearing  left  a  partial  monoplegia. 

Sensory  disturbances  are  as  a  rule  very  slight.  At  the 
beginning  of  the  illness,  as  noted  before,  there  are  fre- 


96  EPIDEMIC    ENCEPHALITIS 

quently  generalized  pains.  The  pains  may  be  localized, 
however,  and  be  associated  with  hyperaesthesia.  Hyper- 
aesthesias  in  portions  of  the  surface  supplied  by  the  fifth 
nerve  are  described  but  are  infrequent.  The  cranial 
nerve  palsies  are  frequently  bilateral,  almost  always 
incomplete  and  may  be  transient  or  variable. 

Mental  Symptoms.  Any  of  the  three  cardinal  symp- 
toms given  by  Netter,  namely,  lethargy,  fever,  and  cranial 
nerve  palsies,  may  be  absent;  but  the  one  most  frequently 
present  is  probably  somnolence,  stupor  or  lethargy.  At 
the  onset  of  the  illness  the  mental  symptoms  are  fre- 
quently irritative,  and  delirium  with  hallucinations  and 
tlelusions  is  often  noted.  This  is  more  apt  to  occur  at  night 
and  may  be  present  when  in  the  day  time  the  mental 
state  is  that  of  stupor  with  normal  rationalit^^  The  onset 
of  the  drowsiness  is  usually  some  days  after  the  first 
sj^mptoms  have  appeared.  At  first  it  is  simply  a  drowsi- 
ness with  a  constant  desire  to  sleep.  In  a  few  daj^s  there 
is  more  pronounced  somnolence  and  lethargy.  The  pa- 
tient may  as  a  rule  be  aroused  easily  when  apparently 
in  deep  stupor  and  when  aroused  show  a  normal  intel- 
lectuality, being  well  oriented,  having  a  good  memory, 
and  often  showing  a  surprising  keenness  of  perception 
and  realization  of  what  is  taking  place  about  him.  Some 
of  the  patients  show  a  marked  degree  of  jocularity,  turn- 
ing everything  to  joke  or  witticism.  Frequently  there  is 
a  striking  absence  of  the  appreciation  of  the  seriousness 
of  their  condition,  and  an  entire  lack  of  anxiety  or  fear 
as  to  the  eventual  outcome  of  their  illness.  In  some 
instances,  especially  in  the  abortive  type,  there  is  no 
lethargy  and  merely  a  tendency  to  somnolence  from 
which  they  are  easily  aroused.  For  some  reason  which  is 
difficult  to  explain,  the  groups  which  are  classed  as  the 


STUDIES  OF  SELECTED  CASES 


97 


Fk;.   14. — Internal  Cap,sul(  .     JJi 


98  EPIDEMIC    ENCEPHALITIS 

paralysis  agitans  type  are  less  apt  to  have  deep  lasting 
stupor  than  are  the  other  varieties.  There  is  generally  a 
lack  of  spontaneity  and  initiative.  The  patients  rarely 
speak  except  in  answer  to  direct  questions.  They  are 
acutely  aware  of  pain  on  catheterization  and  of  dis- 
comfort when  the  bed  is  wet  with  urine.  However,  they 
may  not  ask  to  have  their  bladder  or  rectal  functions 
relieved. 

Fever.  A  moderate  degree  of  fever  is  usually  present 
at  the  onset.  It  generally  ranges  from  100  to  102  degrees, 
and  may  be  associated  with  chilly  sensations  but  rarely 
a  shaking  chill.  The  initial  fever  usually  continues  but  a 
few  days,  and  then  entirely  or  nearly  disappears.  In 
some  of  the  severe  and  fatal  cases,  after  a  varying  period 
(often  several  weeks)  it  gradually  rises  again,  associated 
with  rapid  respiration  and  increased  pulse  rate,  until  it 
reaches  106  or  107  degrees.  This  is  a  very  ominous  sign 
and  usually  precedes  a  fatal  termination.  On  the  other 
hand,  there  may  be  practically  no  fever  during  the  en- 
tire course  of  the  illness  even  if  it  ends  fatally.  This  is 
especially  true  in  the  group  where  the  brain  stem  is  the 
portion  mainly  involved  (Case  V). 

Ocular  Symptoms.  Manifestations  due  to  interference 
with  the  oculomotor  apparatus  have  been  present  in 
53  per  cent  of  the  reported  cases.  The  onset  of  the  ocular 
symptoms  is  usually  coincident  with  the  drowsiness,  but 
may  be  the  first  symptom,  or  may  not  occur  until  several 
weeks  after  the  inception.  Ptosis  is  one  of  the  most  fre- 
quent manifestations.  It  is  rather  unusual  in  appearance, 
resembling  that  seen  in  hysteria  or  myasthenia  gravis, 
being  partial  and  without  attempted  compensation  on 
the  part  of  the  patient  by  raising  the  corresponding 
e^yelirow.  At  times  there  is  no  ptosis  but  the  eyes  are 


STUDIES  OF  SELECTED  CASES 


99 


B&'^V'*'   '  \S 


Fig.    15. — Intinual    Ciipsule    Showing    Advi'iitituii   l>yiiii)h    ^i)ace 
Infiltration. 


100  EPIDEMIC    ENCEPHALITIS 

kept  partially  closed  on  account  of  photophobia.  Stell- 
wag's  sign,  or  infrequent  winking,  is  often  present 
when  there  is  a  stupor  or  lethargy.  One  patient 
was  observed  four  and  a  half  minutes  before  winking 
occurred. 

Markedly  varying  forms  of  ocular  palsies  are  found,  A 
complete  third  or  sixth  nerve  paralysis,  such  as  is  com- 
monly produced!  ^^  syphilis,  is  infrequently  observed. 
There  is  rarely  a  simple  internal  or  external  ophthal- 
moplegia, the  findings  being  usually  a  partial  combination 
of  the  two.  The  picture  usually  points  to  nuclear  or  supra- 
nuclear lesions.  Conjugate  deviation  and  limitation  of  the 
voluntary  movement  of  the  eyes  in  a  horizontal  or 
vertical  plane  may  be  present.  In  Case  II,  Part  II,  there 
was  a  slight  conjugate  deviation  upward  and  an  in- 
ability to  look  downward.  For  a  short  period  another 
patient  (Case  V)  showed  limited  lateral  movement  to 
either  side,  while  there  was  an  inability  to  converge  or 
to  look  either  up  or  down.  Nystagmus  or  nystagmoid 
movements  are  frequently  seen.  In  the  patients  the 
writer  has  observed  there  has  been  more  of  a  slight 
rhythmic  nystagmoid  movement  on  contraction  of  a 
paresed  muscle  than  a  distinct  nystagmus.  Paralysis 
of  accommodation  with  normal  pupillary  reaction  may 
occur  as  in  botulism  or  post-diphtheritic  paralysis.  It 
may  be  bilateral  and  the  onlj^  evidence  of  ocular 
involvement. 

The  findings  in  any  given  case  frequently  cannot  be 
assigned  to  lesions  of  any  particular  neuromuscular 
group,  but  can  only  be  explained  on  a  basis  of  incomplete 
involvement  of  several  elements  of  the  oculomotor 
nuclei.  Moderate  degrees  of  swelling  of  the  disc  are 
found  commonly,  but  never  the  severer  grades  of  choked 


STUDIES  OF  SELECTED  CASES 


101 


it 


Fig.   16. — Internal  Capsule,  Showing  Adventitial  Lj'mph  Space 
Infiltration. 


102 


EPIDEMIC    ENCEPHALITIS 


disc.  Photophobia  is  frequently  present  but  is  usually 
not  severe. 

The  ocular  findings  which  are  more  or  less  char- 
acteristic of  this  condition  may  be  summarized  as 
follows: 


>  ,< 


-M-^':^^^ 


m 


Fig.  17. — Medulla.     Hemorrhage,      Infiltration     and      Vascular 
Changes  in  Substantia  Reticularis  Grisea. 


1 .  There  is  rarely  clear-cut  complete  paralysis  of  anj^ 
one  oculomotor  nerve. 

2.  The    disturbances    are    very   frequently    bilateral. 


STUDIES  OF  SELECTED  CASES 


103 


3.  The  paresis  is  usually  partial  and  involves  more  than 
one  or  only  part  of  one  neuromuscular  group. 

4.  Ptosis  is  the  most  common  isolated  ocular  finding. 
It  is  partial  and  uncompensated  by  contraction  of  the 
frontalis. 


Fig.   18. — Medulla.     Localized  Cellular  lufiltiatioii  ul'   Furinatio 
Reticularis  Grisea, 

5,  Unilateral  or  bilateral  paralysis  of  accommodation, 
dissociated    from    pupillary    involvement,    may    occur. 

6.  The  ocular  jxalsios  are  frequently  not  stationary 
having  a  tendency  to  alteration,  in  some  instances  even 
from  day  to  day. 


104  EPIDEMIC   ENCEPHALITIS 

7.  Lesions  of  the  fundus  are  usually  absent,  but  there 
may  be  a  slight  degree  of  papilledema. 

BLOOD    EXAMINATION 

The  blood  count  does  not  show  constant  alteration, 
though  there  is  usually  a  moderate  leucocytosis.  Vaidya''^ 
reports  observations  in  twenty  cases.  The  highest 
count  in  his  series  was  14,000,  and  the  lowest  4,000, 
with  an  average  of  8,000  to  9,000.  The  differential  count 
showed  approximately  normal  proportions. 

In  twelve  cases  of  this  series  in  which  blood  examina- 
tions have  been  made  the  lowest  was  7,700  and  the 
highest  29,700,  the  average  count  being  about  15,000. 
The  differential  count  showed  no  constant  variation  from 
the  normal.  The  Wassermann  reaction  is  negative,  and 
the  blood  cultures  sterile. 

SPINAL    FLUID 

In  the  great  proportion  of  cases  reported  the  spinal 
fluid  has  been  normal.  Some  observers  report  increased 
cells  counts  and  globulin  in  every  case,  while  others 
have  never  seen  any  abnormalities. 

The  pressure  may  be  normal,  but  it  is  frequently  in- 
creased. This  is  usual  in  the  early  stages  of  the  disease, 
while  later  on  it  is  normal  or  occasionally  decreased, 
as  has  been  observed  several  times  shortly  before  death. 

The  appearance  has  in  all  cases  been  perfectly  clear  and 
colorless,  except  for  one  case  reported  by  Wilson,  where 
one  puncture  gave  fluid  which  was  slightly  yellowish 
and  was  probably  due  to  hemorrhages  into  the  lepto- 
meninges.  Subsequent  spinal  puncture  in  this  case  gave 
a  clear  colorless  fluid. 

Globulin  is  usually  absent  but  may  be  reported  as  plus 


STUDIES  OF  SELECTED  CASES 


105 


or  minus  or  present  only  in  the  minutest  trace.  Where 
there  is  a  pleocytosis  it  is  frequently  present. 

The  cell  count  is  generally  normal  but  is  increased  in  a 
minor  proportion  of  cases.  The  cells  are  small  lympho- 
cytes and  if  increased  are  usually  only  moderately  so, 


-iA^ 

**v 

'v; 

•*■ 

M^' 

',(  '•  '■ 

m 

"•>'. 

Fig.   19.— Medulla.     Diffuse  Infiltration. 

the  cell  counts  showing  10  to  30  cells  per  cubic  milH- 
meter;  but  counts  of  200  cells  and  over  have  been 
reported. 

The  Wassermann  reaction  is  negative  in  all  dilutions. 
Cultures  are  sterile.   Organisms  have  been  cultivated 


lOG 


EPIDEMIC    ENCEPHALITIS 


from  the  spinal  fluid  in  isolated  cases,  but  never  con- 
stantly, and  they  have  been  considered  contaminations. 
The  colloidal  gold  curve  in  the  few  cases  in  which  it 
has  been  examined  is  usually  negative.  Case  X  of  this 
series    had    a   trace   of   globulin,  23   cells,  and  a  gold 


Fig.  20.— ^Medulla.     Ac.uti;  Cloudy  Swelling  in  the  Cells  of  the 
Nucleus  Ambiguus. 

curve  of  the  meningitic  type  (122  343210  0). 

Fehling's  solution  always  shows  a  normal  reduction. 

It  seems  logical  to  suppose  that  the   changes  in  the 
spinal  fluid  are  present  in  the  cases  in  wliich  there  is 


STUDIES  OF  SELECTED  CASES        107 

cortical  hemorrhage  or  meningeal  inflammation.  As 
this  is  very  slight  or  absent  in  the  majority  of  instances, 
the  spinal  fluiil  would  be  expected  to  show  no  pathological 
alterations. 


Fig.  21. — Medulla.      Formatio     Reticularis     Grisea.      Fat     Pig- 
mentary Degeneration  of  One  of  the  Nerve  Cells. 


PROGNOSIS 

At  the  present  time,  as  our  knowledge  of  epidemic 
encephalitis  is  based  on  but  a  few  months'  observation 
and  study,  it  is  impossible  to  obtain  accurate  data  or 
give  reliable  statistics  as  to  the  termination  of  this  disease. 


108 


EPIDEMIC    ENCEPHALITIS 


Fig.  22. — Cortical    White    Matter.     Occipital    Lobe.     Localized 
Accumulations  of  Ameboid  Neuroglia  Cells. 


STUDIES  OF  SELECTED  CASES        109 

In  discussing  the  prognosis  we  must  consider  it  not  only 
as  to  life,  but  also  as  to  completeness  of  restitution. 
The  mortality  as  given  by  different  observers  varies 
considerably,  as  may  be  seen  from  the  following  statistics : 

NO.  OF  CASES  FATAL 

Economo 11  6 

Netter 15  7 

VonWiesner 13  2 

Findlay 3  1 

Wilson,  K 13  2 

Tilney  and  Riley"" 20  6 

Hall 16  0 

Abrahamson' 52  5* 

Total 143  29 

In  113  cases  reported  in  the  literature  in  which  the 
condition  at  the  time  of  writing  or  the  termination  was 
given,  and  including  those  pei'sonally  observed,  the 
statistics  are  as  follows: 

CASES  PER  CENT 

Fatal 35  30.9 

Recovered 29  25 . 6 

Improved 37  32 . 7 

Stationary 12  10.6 

The  prognosis  at  the  time  of  onset  in  all  cases  .should 
be  guarded.  While  the  termination  in  any  one  type  may 
be  fatal,  some  varieties  generally  have  a  more  hopeful 
outlook  than  others.  The  group  with  general  symptoms 
but  without  any  localizing  signs  has  a  mortality  which 
is  in  direct  relation  to  the  intensity  and  duration  of  the 
lethargy.  This  group  as  a  whole  has  a  rather  grave  out- 
look, although  many  of  the  milder  cases  completely  re- 
cover. The  occurrence  of  increasing  temperature,  pulse 
and  respiratory  rates  is  very  ominous,  death  following  in  a 

*  "About  10  per  cent"  of  52  cases. 


no 


EPIDEMIC    ENCEPHALITIS 


week  or  ten  days.  Acute  delirium  or  continued  irrational- 
ity are  unfavorable.  The  paralysis  agitans  type  has  a 


Fig.  23. — Chromatolysis  and  Acute  Cloudy  Swelling  in  the  Cells 
of  the  Anterior  Horns  of  the  Spinal  Cord. 

tendency  to  slow  development  and  long  duration.  It  is 
probable  that  in  some  of  the  milder  forms  complete 


STUDIES  OF  SELECTED  CASES 


111 


^ 

■■1 

*;'>  V.     h.  ■ 

ll 

Hm^^^H 

•  V     «  '♦  ♦'/# 

SBiJ^^BB^Bi^^B 

' ,  .f-^'-  ■ 

.y'S' 

IW'     '          1      " 

..';/..'"/■; 

'     ^  ;/    ■ 

'"'^>:-:''S 

■        f.  'V.    /..     .  'v 

•■^:-^/v 

""^V- 

.■>?^(i::V 

s 

'•     "■      A 

'm -''■'-"" S 

•'   J^" 

i  1  ^     A 

I^C'  1        *     *        '    ^    '4 

'  '"m 

r 'i'^l 

•' '                  • .  •'.      ?  '   ,   •    ,  ' 

' 

{  jM^ 

'  -^  ■../  'J. 

"-     f l\  '  "     %' 

,  ■.  ■  ■  /  -  .. 

\yS^' 

•  '  vl 

,  p- 

^      *         ^0                     • 

"  '  ''.    ^  ' 

»  ^ 

,    f    ', 

,   '     '  •      %!^-    **' 

'  * 

/             .* 

'*    *•  •'  .   '\ 

.   i  'v     ' 

.,       . 

' '^'' ' 

.*\ 

r 

■'>■'. 

c 

"     ■ 

-y' 

r-  - '     ' -«» 

sp'_ 

.f 

, 

'4             .    tfjMi 

4    f^ 

'*,'<* 

1  '.    ' 

^,  .' 

.        A*    ■' 

'    ■    '  •     ^                    > 

gg 

■B 

W' 

Fig.  24. — Blood    Vessel    Showing    \  iiclio\\-i{()i)iii    .^pncc    Packed 
with  Lymphocytes. 


112  EPIDEMIC    ENCEPHALITIS 

restitution  does  occur,  but  it  is  too  early  to  tell  what 
amount  of  restitution  takes  place  in  the  severer  cases 
which  survive. 

The  outcome  of  cases  with  evidence  of  severe  lesions 
in  the  pyramidal  tracts  is  also  uncertain,  but  transient 
weakness,  ankle  clonus  and  positive  Babinski  reflexes 
have  been  observed. 

The  greater  proportion  of  the  brain  stem  type  recover, 
though  complete  restitution  may  be  protracted.  The 
ocular  palsies  are  subject  to  variation  and  improve  more 
rapidly  than  do  lesions  of  the  facial  nerve.  Any  of  the 
symptoms  may  be  aggravated  by  fatigue  and  in  this 
way  may  reappear  after  recovery  has  taken  place. 


CHAPTER  XVII 

CASE    REPORT    I 

Mrs.  M.  B.  H.     Aged  fifty-one;  married.  Housewife. 

Chief  Comylaint.  General  weakness  for  four  months, 
dizziness  for  thirteen  days. 

Family  History.  Father  died  at  eight3^-five;  cause 
unknown.  Mother  died  at  seventy-nine  of  cancer  of 
the  breast.  One  sister  died  at  eighty-four  of  cerebral 
hemorrhage.  No  history  of  rheumatism,  heart  disease, 
tuberculosis  or  insanity. 

Personal  History.  Patient  has  been  married  twenty- 
six  years;  husband  is  living  and  well.  She  has  had  three 
children  who  are  living  and  well,  and  three  miscarriages. 
Her  habits  are  good;  she  has  never  used  alcohol  or  drugs. 
There  has  been  no  recent  change  in  weight  which  is  140 
pounds. 

Past  History.  Scarlet  fever  at  nine,  but  without 
complications.  Pleurisy  and  pneumonia  fourteen  years 
ago.  No  operations  or  injuries. 

Head:  Occasional  headaches  for  several  years  attrib- 
uted to  weak  eyes. 

Eyes:  Has  worn  glasses  for  thirty-five  years  for 
astigmatism  and  hypermetropia. 

Ears  and  Nose:     Negative. 

Mouth  and  Throat:    Negative. 

Respiratory:  Fourteen  years  ago  had  "pneumonia 
and  pleurisy."  This  illness  was  short.  There  was  no 
pain  at  that  time,  no  cough,  no  hemoptysis. 

Heart:  Has  never  had  palpitation,  dyspnea  or  swelling 
of  the  feet. 

113 


114  EPIDEMIC    ENCEPHALITIS 

Gastrointestinal:  Appetite  is  good  as  a  rule.  Has  had 
occasional  slight  distress  in  epigastrium  after  meals 
with  some  gaseous  eructations,    but    never    vomiting. 

Bowels:  Always  irregular  and  constipated.  Constipa- 
tion relieved  by  daily  enemata.  Has  had  slight  external 
hemorrhoids  for  the  past  four  years;  no  bleeding. 

Urinary:  Occasional  nocturia;  no  frequency;  no 
dysuria  nor  hematuria. 

Menstrual:  Periods  began  at  the  age  of  thirteen 
and  were  always  regular.  No  dysmenorrhea  or  met- 
rorrhagia. Menopause  began  two  and  a  half  years  ago. 
Periods  ceased  last  April.  Since  that  time  there  has  been 
a  slight  white  vaginal  discharge. 

Extremities:  No  tremor  nor  deformities.  Occasional 
numbness  in  the  hands. 

Present  Illness.  About  four  months  ago  the  patient 
noticed  that  she  could  not  do  her  housework  without 
becoming  exhausted.  About  three  months  ago  she  had 
a  severe  head  cold  characterized  by  profuse  waterj^ 
nasal  discharge,  headache,  and  slight  generalized  pains. 
This  continued  for  about  two  weeks  and  then  gradually 
cleared  up.  There  was  no  fever,  sore  throat,  cough  or 
expectoration.  She  is  not  at  all  subject  to  colds,  this 
being  the  first  one  she  had  had  in  over  three  years.  The 
general  weakness  has  gradually  increased  but  until 
recently  was  accompanied  by  no  other  symptoms. 
Thirteen  days  ago  she  became  dizzy  and  could  not  stand 
up.  She  went  to  bed  and  became  drowsy,  taking  little 
interest  in  what  was  going  on  around  her.  About  this 
time  she  lost  her  appetite.  She  has  had  no  pain,  no  epigas- 
tric distress,  vomiting  or  fever.  Her  main  complaints 
at  present  are  generalized  weakness,  loss  of  appetite, 
slight  headache,  vertigo  and  inability  to  get  in  a  com- 
fortable position  in  hcd.  Her  husband  states  that  she 


STUDIES  OF  SELECTED  CASES        115 

has  always  been  of  an  exceedingly  bright  and  cheerful 
disposition,  while  now  she  has  gradually  developed  a 
staring  expression  and  a  tendency  to  be  drowsy  and 
quiet.  Ther(;  have  been  no  other  mental  changes. 

PHYSICAL  examination:   OCTOBER   27,    1919 

General  Appearaiice.  A  drowsy,  unresponsive  woman 
lying  quietly  in  bed,  with  a  vacant  expression,  eyes 
partially  closed  and  staring  directly  forward,  apparently 
in  no  distress.  She  is  rather  easily  aroused,  and  when 
so  speaks  in  a  slow,  faint,  monotonous,  high-pitched 
voice. 

She  complains  of  extreme  distress  in  all  portions  of  her 
body  especially  below  the  waist,  saying  that  it  is  impos- 
sible to  get  in  a  comfortable  position  and  that  she  has 
been  constantly  turning  in  bed  but  is  unable  to  find  any 
position  in  which  she  can  get  relief.  She  also  states  that 
she  is  drowsy  and  lacks  her  usual  alertness  and  vivacity. 
Although  the  patient  says  that  she  has  been  constantly 
moving  in  bed,  she  was  observed  for  some  time  before 
she  was  aroused,  and  during  this  time  she  made  no  mus- 
cular movement  of  any  kind,  even  winking  only  once  in 
four  or  five  minutes. 

Skin  is  slightly  pale,  dry  and  warm. 

Hair  distribution  is  of  the  normal  female  type. 

Head:     There  is  no  sinus  tenderness  or  deformity. 

Ears:  Brums  are  normal;  there  is  no  mastoid 
tenderness. 

Eyes:  The  lids  are  drooping,  giving  the  appearance 
of  double  ptosis,  though  she  is  able  to  open  them  fully. 
There  is  a  slight  external  strabismus  of  the  right  eye. 
The  conjunctivae  are  a  little  pale.  The  eye  grounds  show 
the  vessels  clear.  The  margins  of  the  discs  are  sliglitly 


116  EPIDEMIC    ENCEPHALITIS 

hazy  but  there  is  no  real  choked  disc.  The  vessels  in  the 
retina  are  normal. 

Nose  is  normal;  no  discharge. 

Mouth:  The  teeth  are  in  good  condition.  The  breath 
is  foul.  There  is  slight  pyorrhea.  The  tongue  is  coated. 
The  tonsils  are  large  with  some  exudate  in  the  mouths 
of  the  tonsillar  crypts.  The  pharynx  is  slightly  congested. 
On  smiling  the  mouth  is  drawn  slightly  to  the  right. 
The  whistling  sound  is  normal. 

Neck  is  slightly  stiff  but  there  is  no  distinct  rigidity. 
Superficial  lymph  nodes  are  not  enlarged.  Thyroid  is 
not  palpable.  There  are  no  visible  pulsations. 

Thorax  is  well  developed  and  the  breasts  are  soft. 
There  are  no  masses. 

Heart  is  slightly  rapid;  regular;  pulses  equal  and  of 
good  quality.  The  cardiac  outline  is  normal;  the  first 
sound  at  the  apex  is  rather  sharp  and  snapping.  There  are 
no  murmurs,  no  accentuation  of  the  aortic  second  sound. 

Pulse  rate  is  98.  Blood  pressure  is  110-80. 

Lungs  are  clear  and  resonant  throughout. 

Abdomen  is  soft  and  slightly  obese.  No  tenderness  or 
rigidity.  The  liver  and  spleen  are  not  palpable.  No  signs 
of  free  fluid. 

Extremities:    No  edema  or  deformity. 

Vaginal  Examination:  Introitus  easily  admits  two 
fingers.  The  cervix  is  in  the  midline,  well  back,  freely 
movable.  There  is  a  slight  horizontal  laceration.  In  the 
right  fornix  close  beside  the  uterus  there  is  a  firm, 
slightly  tender  mass  that  can  be  easily  felt  between  the 
two  hands. 

NEUROLOGICAL   EXAMINATION.'    OCTOBER    29,    1919 

Voluntary  Motor  System.  Abnormal  Attitudes  and 
Deformities.  The  attitude  is  described  above. 


STUDIES  OF  SELECTED  CASES        117 

Gait.  The  patient  walks  slowly,  deliberately  and 
rather  stiffly,  the  feet  lifted  but  slightly  from  the  floor. 

Coordination.  Equilibratory.  Standing  with  feet  to- 
gether, eyes  open,  there  is  slight  irregular  swaying  which  is 
not  accentuated  by  closing  the  eyes. 

Non-equihbratory.  Finger-to-nose,  pointing  and  past- 
pointing  tests  show  no  deviation,  though  the  movements 
are  slow,  stiff  and  with  a  moderate  tremor.  There  is  no 
dysmetria  or  adiadochokinesis. 

Skilled  acts.  There  is  no  dyspraxia.  The  patient  is  able 
to  feed  herself  and  arrange  her  hair. 

Speech.  There  is  no  aphasia  or  dysarthria,  though 
the  speech  is  slow,  weak  and  in  a  rather  high-pitched 
monotone. 

Reflexes: 

Deep  Right  Left 

Jaw 2  2 

Biceps 2  2 

Triceps 2  2 

Radial 2  2 

Ulnar 2  2 

Suprapatellar 2  2 

Patellar 3  3 

Achilles 1  1 

Superficial 

Ciliosi^inal Present  Present 

Supra-umbilical 2  2 

Suprapubic 2  2 

Upper  lateral  abdominal 2  2 

Lower  lateral  abdominal 2  2 

Plantar  flexion 0  0 

Babinski  and  modifications 0  0 

1  =  slight 

2  =  active 

3  =  very  active 

4  =  with  transient  clonus 

5  =  with  permanent  clonus 


118  EPIDEMIC    ENCEPHALITIS 

Ahnor7nal  Involuntary  Movements.  On  voluntary 
movement  there  is  a  slight  but  distinct  tremor  of  the 
hands.  No  other  tremors,  twitchings,  athetoses,  chorei- 
form movements  or  spasms. 

Muscle  Strength.  The  patient  is  able  to  sit  up  in  bed 
and  to  rise  from  the  recumbent  to  the  standing  position. 
Opposed  and  unopposed  movements  of  the  neck,  shoul- 
ders, arms,  forearms,  hands,  fingers,  thighs,  legs,  feet 
and    toes    show    only    a    moderate    general    weakness. 

Muscle  Status.  Contour  and  consistency  normal. 
There  is  a  general  moderate  hypotonia  with  resistance 
to  passive  movement,  with  a  slight,  irregular  cog-wheel 
release. 

Abnormal  Associated  Movements.     Not  tested. 

Nerve  Status.     No  observation. 

General  Sensory.  There  is  no  disturbance  of 
touch,  pain,  temperature,  vibratory,  pressure,  muscle 
tendon  sense  or  stereognostic  perception. 

Cranial  Nerves  and  Head.  Olfactory  Nerve  and 
Nose.     The  sense  of  smell  is  normal  on  each  side. 

Oculomotor  Apparatus.  Visual  acuity  seems  normal. 
Perimetry,  tested  by  the  finger  method,  is  normal. 
Eyegrounds:  There  is  very  slight  haziness  of  the 
periphery  of  the  discs  in  each  eye.  The  pupils  each 
measure  3  millimeters.  The}^  are  circular,  in  the  center 
of  the  iris,  and  regular.  They  react  normally  to  light  and 
on  accommodation.  The  lids  are  partially  closed,  the 
palpebral  fissures  measuring  7  millimeters.  The  lids 
may  be, fully  retracted,  however,  showing  a  thin  white 
line  of  sclera  above  the  cornea.  There  is  no  exophthalmos, 
enophthalmos  or  ptosis.  The  patient  complains  of  photo- 
phobia and  gives  that  as  the  reason  for  partially  closing 
her  eyes.  There  is  no  strabismus  or  other  ocular  devia- 
tion. The  slight  external  stral)ismus  noted  two  days  ago 


STUDIES  OF  SELECTED  CASES        110 

in  the  general  physical  examination  has  disappeared. 
There  is  no  nystagmus  and  the  conjugated  eye  move- 
ments are  normal. 

Acoustic  Nerve  and  Ear.  A  watch  is  heard  6  inches 
from  the  right  ear  and  83'2  inches  from  the  left. 

Trigeminus  Nen;e  and  Mouth.  Voluntary  movements 
of  the  jaw  are  normal  in  all  directions.  The  corneal 
reflexes  are  normal,  and  there  is  no  abnormality  of 
sensation  in  the  fifth  nerve  area. 

Facial  Nerve  and  Face.  Taste  on  the  anterior  two- 
thirds  of  the  tongue  is  normal.  There  is  a  slight  flattening 
of  the  lower  portion  of  the  face  on  the  left  side  and 
diminished  movement  of  the  left  corner  of  the  mouth 
on  speaking.  Slight  weakness  is  also  evidenced  on 
showing  the  teeth.  There  is  no  weakness  of  the  upper 
face  on  either  side.  Secretion  of  tears  and  saliva  are  normal. 

Glossopharyngeus  and.  Vagits  Nerves,  Pharynx  and 
Larynx.  The  uvula  is  in  the  midline.  Palatal  and 
pharangeal  reflexes  are  normal.  Swallowing,  respiratory 
and  cardiac  action  are  normal. 

Spinal  Accessory  Nerve.  There  is  no  paralysis  of 
either  sternomastoid  or  trapezius  muscle. 

Hypoglossal  Nerve  and  Tongue.  The  tongue  is  pro- 
truded in  the  midline  and  can  be  moved  normally  in  all 
directions. 

LABORATORY    EXAMINATIONS    AND    CLINICAL   NOTES 

Blood  Wassermann:  October  27,  1919 

Alcohol  antigen Negative 

Cholesterin  antigen Negative 

Blood  Count:  October  27,  1919 

Red  blood  cells 5,200,000 

Hemoglobin 70  per  cent. 

White  l)lood  cells S,GOO 


120  EPIDEMIC    ENCEPHALITIS 

Polymorphonuclear  leucocytes . .  75  per  cent. 

Large  lymphocytes 10  per  cent. 

Small  lymphocytes 12  per  cent. 

Transitionals 3  per  cent. 

Morphology  of  red  cells Normal 

Urine  Examination:  October  27,  1919  ^ 

Specific  gravity 1 .  025 

Reaction Acid 

Color Yellow 

Turbidity Slight  flocculent  precipitate 

Albumin Very  faint  trace 

Sugar None 

,,.  .     ,  .     ,.         f  Few  squamous  epithelial  cells 

Microscopical  examination,  i  „  i  •,    i  i      .      n 

[  l^ew  white  blood  cells 

Spinal  Puncture:  October  28,  1919 

Amount 10  c.c. 

Pressure Normal 

Appearance Clear,  colorless 

Globulin + 

Cells 43  lymphocytes 

Wassermann 2  c.c.        1  c.c.       .6  c.c.     .2  c.c. 

Alcohol  antigen Neg.         Neg.         Neg.         Neg. 

Cholesterin  antigen . .  .    Neg.         Neg.         Neg.         Neg. 

Eye  Examination:  November  4,  1919  {Dr.  Schoenberg). 

There  is  a  slight  defect  of  convergence  as  shown  by 
diplopia  on  looking  at  near  objects.  The  upper,  temporal 
and  lower  margins  of  the  right  disc  are  indistinct.  The 
same  is  true  of  the  left  disc,  only  that  the  condition  is  a 
little  more  pronounced.  Both  discs  give  one  the  impres- 
sion of  a  mild  optic  neuritis.  There  is  no  ptosis  or  evidence 
of  any  other  paralysis. 

November  10,  1919.  The  mental  attitude  has  bright- 
ened remarkably;  she  is  apparently  quite  normal.  Her 
main  trouble  now  is  constipation  and  gas  in  the  stomach. 


STUDIES  OF  SELECTED  CASES        121 

November  16,  1919.  Physical  examination  reveals 
none  of  the  pathological  findings  formerly  present.  The 
lids  do  not  droop.  The  face  is  more  mobile,  the  voice  less 
monotonous.  There  is  no  catatonia  or  spasticity.  The 
patient  can  get  comfortable  in  bed.  The  gait  is  normal. 
The  chief  complaint  now  is  indigestion,  loss  of  appe- 
tite, and  gas  which  seems  to  be  dependent  upon  her 
constipation. 

Temperature  while  in  the  hospital  ranged  from  98° 
to  100°;  -pulse  90  to  130;  respirations  18  to  24. 

SUMMARY 

The  patient  complained  of  general  weakness  for  four 
months  and  dizziness  for  thirteen  daj^s  following  what 
appeared  to  be  a  nasopharyngitis.  There  was  spasticity, 
general  slowing  down  of  all  movements,  mask-like  face, 
monotonous  voice,  catatonia,  photophobia,  and  a  mild 
grade  of  optic  neuritis.  The  spinal  fluid  showed  a  positive 
globulin  reaction  and  43  cells  with  a  negative  Wasser- 
mann.  The  spasticity  and  mask-like  appearance  cleared 
up  rapidly  and  the  mental  attitude  became  much 
brighter. 

Constipation  and  gastric  distress  were  the  chief  com- 
plaints at  the  last  and  all  signs  of  encephalitis  had  dis- 
appeared. 


CHAPTER  XVIII 


CASE    REPORT    II 


Miss.  M.  K.  Aged  seventeen.  Single.  Stenographer. 

Family  History.  She  is  an  onl}'  child.  Father  died  of 
heart  disease;  mother  is  living  and  well. 

Past  History.  Patient  has  had  the  ordinary  diseases 
of  childhood,  but  no  accidents,  injuries  or  operations. 
She  was  well  previous  to  the  onset  of  the  present  illness. 

Present  Ulness.  On  September  13,  1919,  the  patient 
noted  that  she  had  a  slight  cold  in  the  head.  The  next 
day  there  was  a  thin,  watery  nasal  discharge,  headache, 
pains  in  the  back  and  limbs,  and  a  fever  of  102  degrees. 
That  night  she  had  difficulty  in  sleeping  and  was  slightly 
delirious.  The  next  two  days  her  condition  was  practic- 
ally the  same  except  that  her  pain  and  headache  were 
more  severe  and  she  had  constant  profuse  perspiration 
and  general  weakness.  On  the  fifth  day  she  commenced 
to  feel  drowsy,  and  the  pain,  nasal  discharge  and  dis- 
comfort were  less.  The  sixth  day  double  ptosis  appeared 
and  the  drowsiness  was  more  marked.  The  headache  had 
entirely  disappeared  by  this  time  and  the  coryza  was 
much  improved,  the  stupor  and  ptosis  dominating  the 
picture.  At  this  time  her  muscles  became  very  rigid 
and  there  was  a  marked  resistance  to  passive  movement. 
During  the  next  few  daj's  the  drowsiness  deepened  to 
lethargy  which  continued  until  the  present. 

NEUROLOGICAL  EXAMINATION:      SEPTEMBER   27,    1919 

The  patient  is  lying  in  a  supine  position,  her  mouth 
and  eyes  are  closed,  arms  folded  across  her  chest,  fingers 

122 


STUDIES  OF  SELECTED  CASES 


123 


flexed.  There  is  a  slight  flexion  of  the  thigh  and  leg. 
The  face  is  expressionless  and  the  patient  has  the  appear- 
ance of  one  in  a  normal,  deep  sleep. 

Voluntary  Motor  System.  Abnormal  Attitudes  and 
Deformities.     None  present. 

Gait.     The  patient  is  unable  to  stand  or  walk. 

Coordination.  Finger-to-nose  and  heel-to-knee  tests 
are  performed  slowly  and  stiffly  and  with  some  tremor. 
Normal  precision  in  every  case.  There  is  no  adiado- 
chokinesis. 

Skilled  Acts.  There  is  no  dyspraxia  or  aphasia. 
Speech  is  slow  and  monotonous  and  scarcely  more  than 
a  whisper. 


Reflexes: 

Deep  Right  Left 

Jaw 3  3 

Pectoral 2  2 

Biceps 3  3 

Triceps 3  3 

Radial 3  3 

Ulnar 3  3 

Suprapatellar 3  3 

Patellar 3  3 

Achilles 3  3 

Superficial 

Ciliospinal Present  Present 

Supra-umbilical Present  Present 

Suprapubic Present  Present 

Upper  lateral  abdominal Present  Present 

Lower  lateral  abdominal Present  Present 

Plantar  flexion Present  Present 

Babinski  and  modifications Absent  Absent 

Abnormal    Involuntary    Movements.     There    are    no 

tremors,  twitchings,  choi'eiform  or  athetoid  movements 

except  on  voluntarj'  exertion,  such  as  touching  the  nose 


124  EPIDEMIC    ENCEPHALITIS 

with  the  finger,  when  there  is  a  rather  coarse  tremor  of 
the  whole  extremity. 

Muscle  Strength.  The  patient  is  unable  to  rise  from 
the  recmnbent  to  the  sitting  position.  All  the  movements 
of  her  extremities  are  very  weak,  but  are  equal  on  the 
two  sides. 

Muscle  Status.  There  is  a  marked  hypertonic  condi- 
tion of  the  general  musculature  giving  rise  to  a  marked 
spasticity.  The  arms  and  legs  will  be  held  in  a  position 
in  which  they  are  passively  placed  if  it  requires  no 
muscular  effort  to  retain  them  in  that  position. 

Ahnormal  Associated  Movements.     Not  tested. 

Nerve  Status.     No  observation. 

General  Sensory.  Examination  difficult  and  inac- 
curate because  of  the  incooperation  of  the  patient. 
However,  touch,  pain,  temperature  and  pressure  senses 
seem  normal. 

Cranial  Nerves  and  Head.  Olfactory  Nerve  and 
N^ose.     Sense  of  smell  not  tested. 

Optic  and  Oculomotor  Apparatus.  Visual  acuity  in 
each  eye  is  normal.  Perimetry,  roughly  tested,  shows  no 
field  contraction.  Eyegrounds  are  normal,  discs  well 
outlined,  no  papillo-edema.  Pupils  are  in  mid-dilatation, 
regular  and  equal.  They  react  actively  to  light  and  on 
accommodation.  The  eyes  are  closed  but  can  be  opened 
to  about  half  the  normal  extent,  the  right  shghtly  less, 
however,  than  the  left.  There  is  no  exophthalmos  or 
enophthalmos.  There  is  a  moderate  external  strabismus 
in  the  right  eye,  which,  however,  is  said  to  be  congenital. 
Conjugated  eye  movements:  Motihty  is  good  up,  to 
the  right  and  left,  but  there  seems  to  be  an  inability 
to  look  down.  There  is  no  nystagmus. 

Trigeminus  Nerve  and  Mouth.  The  movements  of  the 
jaw  are  equal  and  normal  in  all  directions.  The  jaw 
reflexes  are  active,  the  corneal  reflexes  present. 


STUDIES  OF  SELECTED  CASES        125 

Acoustic  Nerve  and  Ear.  Hearing  is  normal  on  each 
side. 

Facial  Nerve  and  Face.  There  is  no  facial  weakness  or 
paralysis  on  either  side. 

Glossopharyngeus  and  Vagus  Nerves,  Pharynx  and 
Larynx.  The  uvula  is  in  the  midline.  Palatal  and 
pharyngeal  reflexes  are  normal.  Swallowing  and  respira- 
tion are  also  normal. 

Spinal  Accessory  Nerve.  No  evidence  of  paralysis 
of  either  sternomastoid  or  trapezius  muscle. 

Hypoglossus  Nerve  and  To7igue.  The  tongue  is  pro- 
truded in  the  midline  and  its  movements  are  equal  in  all 
directions. 

Mental  Status.  The  patient  seems  alert  to  all 
that  is  going  on  about  her.  She  rarely  speaks  unless 
aroused  and  then  usually  only  in  answer  to  direct  ques- 
tions. She  worries  somewhat  about  her  work  and  to  a 
less  extent  about  her  own  condition,  but  has  no  somatic 
complaints. 

General  Physical  Examination  is  practically  nega- 
tive. The  heart  and  lungs  are  normal.  The  liver  and 
spleen  are  not  palpable.  There  is  generally  a  slight  ab- 
dominal distension.  Sweating  is  profuse.  There  are  no 
enlarged  lymph   nodes.   The   thyroid  is   not   palpable. 

Spinal  Puncture:  September  28,  1919 

Appearance Perfectly  clear 

Pressure Normal 

Cells 5  lymphocytes 

Globulin Negative 

Fehling Normal  reduction 

Clinical  Notes.  Patient's  eyes  were  closed  most  of 
the  time  but  she  was  able  to  open  them  to  about  one  half 
of  the  normal  extent.  If  there  was  light  in  the  room  she 


126  EPIDEMIC   ENCEPHALITIS 

would  always  keep  them  closed;  but  if  the  gas  were 
turned  down  she  would  almost  always  open  them. 
If  they  were  closed  and  the  light  from  a  pocket  flash- 
light suddenly  flashed  on  them,  the  lids  would  be  closed 
more  tightly.  There  was  a  slight  external  strabismus  of 
the  right  eye,  but  this  had  been  present  since  childhood. 

During  the  second  week  of  her  illness  there  developed 
an  inability  to  look  downward,  though  she  could  turn 
the  eyes  upward  and  move  them  laterally.  The  pupillary 
reflexes  were  active  throughout  the  entire  course  of  her 
illness. 

Her  mental  state  was  practically  the  same  as  it  had 
been  before  the  illness  commenced.  There  was  at  no 
time  any  tendency  to  joke,  laugh  or  smile  which  is  so 
marked  in  some  patients  with  this  disease.  At  all  times 
she  seemed  particularly  alert  to  everything  that  was 
going  on  about  her.  She  would  hear  knocks  at  the  door 
that  were  not  heard  by  her  mother  or  the  nurse,  and 
would  tell  them  to  open  the  door.  Usually  she  would 
not  speak  spontaneously  or  ask  for  anything,  but  if  she 
were  aroused  she  would  talk  and  would  show  that  she 
was  cognizant  of  the  happenings  about  her.  She  would 
never  volunteer  information  that  she  desired  to  empty 
her  bladder  or  bowel,  and  occasionally  passed  her  urine 
involuntarily,  but  being  aroused  at  regular  intervals  she 
was  able  to  evacuate  both  bladder  and  bowel  normally. 
There  was  no  voluntary  attempt  made  to  move  and  after 
remaining  in  one  position  for  a  long  time;  if  aroused  she 
would  ask  to  be  moved  but  would  make  no  effort  to 
move  herself.  If  asked  to  move  her  arms  or  limbs  she 
would  do  so,  but  the  movements  were  slow  and  trembling. 

There  was  no  real  paralysis  of  any  part.  During  the 
first  three  weeks  of  her  illness  there  was  a  pronounced 
increase  in  the  muscle  tone  which  gave  rise  to  a  general 


STUDIES  OF  SELECTED  CASES 


127 


rigidity,  but  there  was  no  tendency  to  hold  the  limbs  in 
any  position  in  which  they  were  placed  if  this  required 
any  muscular  effort. 

In  the  third  week  of  her  illness  there  were  two  short 
convulsions  which  consisted  of  a  tightening  of  the  jaw, 


Fig.  25.— Case     11.     Temperature    and     Pulse    Chart     During 

Final  Week  of  Illness. 

Temperature        Pulse 

a  spasm  of  the  respiratory  muscles  and  general  tonic 
contractions  of  the  musculature. 

In  the  sixth  week  the  temperature  rose  from  between 
99°  and  100°,  which  was  the  level  it  had  been  maintaining 
since  the  drowsiness  had  come  on,  to  103°  and  104°. 
The  pulse  increased  from  between  90  and  100  to  between 
120   and    150,  and   respirations   from    18-22  to   80-50. 


128  EPIDEMIC    ENCEPHALITIS 

At  one  time  the  respirations  were  60,  the  temperature 
107  and  the  heart  rate  185.  (The  pulse  could  not  be 
counted  at  the  wrist.)  At  about  the  same  time  the 
spasticity  became  much  less  marked  and  it  was  more 
difficult  to  arouse  the  patient;  but  when  aroused,  she 
seemed  to  understand  what  was  said  to  her  though 
she  made  no  effort  to  speak. 

On  the  42nd  day  of  her  illness  she  died  from  respiratory 
paralysis. 

SUMMARY 

The  illness  commenced  with  symptoms  similar  to 
those  of  influenza,  with  restlessness  and  delirium.  Soon 
these  gave  way  to  somnolence  and  lethargy  which  con- 
tinued until  the  end,  and  dominated  the  clinical  picture. 
The  main  findings  on  neurological  examination,  outside 
of  the  mental  state,  were  general  muscular  spasticity, 
double  ptosis,  and  an  inability  to  look  downward. 
The  course  was  practically  stationary  until  a  week 
before  death,  when  there  was  greater  stupor,  increasing 
pulse,  respiratory  rate  and  temperature,  with  decided 
lessening  of  the  general  rigidity. 


CHAPTER  XIX 


CASE    REPORT    III 


Mr.  G.  A.  D.,  Aged  twenty-nine,  Married.  Chauffeur. 
Admitted  to  the  hospital  November  9,  1919. 

Chief  Complaints.  General  weakness  for  three  weeks; 
blurring  of  vision  for  two  and  a  half  weeks. 

Family  History.  Both  parents  are  living  and  well. 
One  brother  and  three  sisters  are  also  living  and  well. 
One  brother  died  of  lobar  pneumonia.  No  history  of 
tuberculosis,  rheumatism,  heart  trouble  or  Bright's 
disease  in  the  family. 

Personal  History.  Patient  was  born  in  the  United 
States  and  has  been  married  three  years.  His  wife  and 
two  children  are  living  and  well.  The  last  pregnancy 
resulted  in  miscarriage  the  cause  of  which  is  unknown. 
He  eats  regularly;  takes  an  occasional  glass  of  beer  or 
whiskey  but  never  in  excess,  smokes  twenty  cigarettes  a 
day.  His  occupation  is  that  of  an  automobile  repair  man. 
He  has  been  working  at  night  for  the  past  six  weeks. 

The  average  weight  is  187  pounds;  he  has  lost  25 
pounds  since  the  onset  of  the  present  illness. 

Previous  History.  No  acute  infectious  diseases.  Ampu- 
tation of  the  ring  finger  of  the  right  hand  several  years 
ago. 

Head:    No  headaches. 

Eyes:  Vision  was  entirely  normal  up  to  the  present 
illness.  Occasionally  on  rising  suddenly  after  stooping, 
he  has  had  an  attack  of  dizziness  in  which  "everything 

129 


130  EPIDEMIC    ENCEPHALITIS 

gets  black."  This  continues  for  only  a  minute  or  two. 
He  has  had  about  twelve  of  these  attacks  during  the 
past  nine  years. 

Nose:     Negative.     Throat:     Negative. 

Teeth :     Always  in  good  condition. 

Respiratory :     Is  not  subject  to  colds. 

Cardiac:  No  dyspnea  on  exertion;  no  swelling  of  the 
feet. 

Gastrointestinal:  Appetite  good.  No  constipation 
until  the  present  illness.  Never  jaundiced. 

Geriito-Urinary :  No  nocturia.  Gonorrhoea  twice,  in 
1908  and  1909.  Syphilis  denied  by  name  and  symptom. 

N  euro-Muscular:  Negative  prior  to  the  present 
illness. 

Present  Illness.  The  onset  occurred  three  weeks  ago 
in  the  form  of  chilly  sensations  followed  by  fever.  He 
would  have  three  or  four  chills  a  day  followed  each  time 
by  a  rise  in  temperature.  The  chills  would  be  slight  and 
last  about  three-quarters  of  an  hour,  while  the  fever 
continued  for  one  or  two  hours.  He  was  given  quinine 
and  whiskey  but  without  relief.  About  two  weeks 
ago  he  developed  general  weakness  and  lassitude  and  at 
the  same  time  had  insomnia  which  is  still  present. 
He  says  he  does  not  sleep  either  during  the  day  or  at 
night.  Two  weeks  ago  he  noticed  blurring  of  vision  on 
attempting  to  read.  This  got  rapidly  worse  until  the 
present  when  he  is  unable  to  read  even  the  largest 
headlines  in  the  newspaper.  Far  vision,  however,  is 
normal.  There  has  been  no  diplopia  nor  headache.  Con- 
stipation has  been  present  since  the  onset.  There  is  no 
muscle  twitching  nor  photophobia. 

Physical  Examination.  General  Appearance  is  that 
of  a  well  nourished,  well  developed  young  adult  man 
lying  stiffly  in  bed,  appearing  neither  acutely  nor  chron- 


STUDIES  OF  SELECTED  CASES 


131 


ically  ill.  His  expression  is  mask-like.  His  movements 
are  few  and  slow. 

Skin  is  dry,  coarse  and  cool. 

Superficial  lymph  nodes  not  palpably  enlarged. 

Head  is  oblong-shape,  prominent  square  chin. 


Case  III. 


Eyes:  Conjunctivae  are  slightly  congested.  There  is  a 
slight  twitching  of  both  eyelids.  No  strabismus  or  nystag- 
mus. Eyegrounds:  The  nasal  side  in  both  optic  discs 
is  hazy,  the  right  slightly  more  marked  than  the  left. 
The  fundi  are  otherwise  normal. 

Ear-drums  are  normal;  there  is  no  mastoid  tenderness. 

Nose:     Negative. 


132  EPIDEMIC    ENCEPHALITIS 

Mouth:  Buccal  mucosa  negative.  The  tongue  is  a 
grajdsh-brown,  covered  with  a  thick,  dry  coat. 

Teeth  are  well  preserved.  The  gums  show  beginning 
pyorrhea. 

Throat  is  slightly  congested.  Tonsils  are  small  and  not 
diseased. 

Neck:  There  is  slight  limitation  of  extreme  flexion. 
No  pronounced  rigidity. 

Chest  is  well  developed;  expansion  good  and  equal  on 
both  sides. 

Lungs:  There  is  slight  relative  dullness  over  the  sec- 
ond and  third  left  interspaces;  otherwise  the  lungs  are 
clear  throughout  except  for  a  few  rales  at  the  right  base 
which  disappear  after  coughing. 

Heart  is  normal  in  outline.  The  sounds  are  of  good 
quality;  action  is  regular;  no  murmurs.  The  pulse  is  64, 
regular  and  full;  the  vessel  wall  is  not  palpable.  Blood 
pressure  120-75. 

Abdomen  is  markedly  retracted  with  considerable  vol- 
untary spasm.  No  viscera  or  masses  felt. 

External  Genitalia:     Negative. 

Rectal  Examination:  The  prostate  is  small  and 
smooth.  No  masses. 

Extremities:  Movements  are  slow  with  diminished 
strength.  The  third  finger  of  the  right  hand  is  missing. 

NEUROLOGICAL    EXAMINATION:   NOVEMBER  13,  1919 

General  Appearance.  The  patient  is  lying  dorsally  in 
bed  with  his  arms  crossed  on  his  chest.  His  eyelids  are 
partially  closed,  the  eyes  directed  forward  with  a  fixed, 
emotionless  stare.  The  mouth  is  symmetrical  and  held 
partially  open.  There  is  a  waxy,  death-like  appearance 
of  the  entire  face.  He  is  easily  aroused  and  when  so  speaks 
rather  slowly,  but  answers  all  questions  clearly  and  gives 
no  evidence  of  lack  of  intelligence  or  defective  cerebra- 


STUDIES  OF  SELECTED  CASES        133 

tion.  If  he  is  left  alone  and  his  attention  is  not  centered 
on  what  is  going  on  about  him,  he  rapidly  sinks  back  into 
liis  previous  apathetic  state. 

Voluntary  Motor  System.  He  is  able  to  stand  and 
walk.  The  movements  are  a  little  slow  and  unsteady, 
but  the  difficulty  seems  to  be  due  to  weakness  rather 
than  to  incoordination.  Standing  with  his  feet  together 
he  swaj^s  slightly  but  not  more  so  when  his  eyes  are 
closed.  Finger-to-nose,  heel-to-knee,  pointing  and  past 
pointing  tests  are  accurately  though  not  rapidly  per- 
formed. Dysmetria  and  adiadochokinesis  are  absent. 

Skilled  Acts.  There  ia  no  dyspraxia,  dysarthia  or 
aphasia.  His  voice  is  rather  slow,  soft,  and  without  much 
inflection. 

Reflexes: 

Deep  Right  Left 

Jaw 2  2 

Pectoral 2  2 

Biceps 2  2 

Triceps 2  2 

Wrist 2  2 

Radial 2  2 

Ulnar ■...  2  2 

Suprapatellar 1  1 

Patellar 2  2 

Achilles 2  2 

Superficial 

Supra-uin1>ilical 0  2 

Suprapubic 0  2 

Upper  lateral  abdominal 0  2 

Lower  lateral  abdominal 0  2 

Cremasteric 2  2 

Plantar  flexion 2  2 

Bal)inski  and  modifications 0  0 

Abnormal  Involuntary  Movements.  There  are  no  tre- 
mors, twitchings,  spasmodic  movements  or  convulsions. 

Muscle  Strength.  He  is  able  to  rise  from  the  recumbent 
position  to  sitting  or  standing.  Flexion,  extension  and 


134  EPIDEMIC    ENCEPHALITIS 

rotation  of  the  trunk  and  extremities  show  average 
strength  everywhere.  Symmetrical  movements  are  equal. 

Muscle  Status.  Contour  and  consistency  are  normal. 
There  is  slight  but  general  hypertonia  with  some  resist- 
ance to  passive  movement  but  no  suggestion  of  irregular 
cog-wheel  release. 

General  Sensory.  Touch,  pain,  vibratory,  pressure, 
muscle  tendon  sense  and  stereognostic  perception  are 
normal. 

Cranial  Nerves  and  Head.  Olfactory  Nerve  and 
Nose.     Sense  of  smell  is  normal  in  each  nostril. 

Optic  and  Oculomotor  Apparatus.  Vision  is  normal 
for  distance.  Objects  more  than  10  or  15  feet  away  are 
seen  perfectly  distinctly,  but  there  is  no  ability  to  accom- 
modate, so  that  near  objects  are  blurred  and  indistinct. 

Perimetry,  with  the  finger  test,  is  normal. 

Eyegrounds  show  a  very  slight  haziness  of  the  nasal 
side  of  the  disc  in  each  eye,  but  no  hemorrhages  or  other 
abnormality. 

Pupils:  The  right  pupil  is  larger  than  the  left,  being 
6  millimeters,  while  the  left  is  4  millimeters  in  diameter. 
There  is  no  eccentricity  or  irregularity.  Both  react  to 
light  and  on  convergence. 

Palpebral  fissures:  Occasionally  the  right  appears 
larger  than  the  left,  but  at  other  times  they  are  equal. 
There  is  certainly  very  little  difi'erence.  There  is  no  ex- 
ophthalmos, enophthalmos  or  ptosis.  There  is  no  stra- 
bismus, other  ocular  devation  or  nystagmus. 

Acoustic  Nerve  and  Ear.  Hearing  is  normal  in  each 
ear. 

Trigeminus  Nerve  and  Mouth.  There  are  no  sensory 
disturbances  and  movements  of  the  jaw  are  normal  in 
all  directions. 

Facial  Nerve  and  Face.     There  is  no  evident  weakness 


STUDIES  OF  SELECTED  CASES        135 

of  either  upper  or  lower  branches  of  the  facial  nerve  on 
either  side. 

Glossopharyngeus  and  Vagus  Nerves,  Pharynx  and 
Larynx.  The  uvula  is  in  the  midline.  The  palatal  re- 
flexes and  pharyngeal  reflex  are  normal.  Swallowing  is 
performed  without  difficulty.  , 

Spinal  Accessory  Nerve.  Movements  of  the  sterno- 
mastoid  and  trapezius  muscles  are  normal  and  equal  on 
the  two  sides. 

Hypoglossus  Nerve  and  Tongue.  The  tongue  is  pro- 
truded in  the  midline;  its  movements  are  normal  in  all 
directions  and  there  is  no  tremor. 

LABORATORY    EXAMINATIONS    AND    CLINICAL    NOTES 

Blood  Count:     November  11,  1919. 

Red  blood  cells 5,000,000 

Hemoglobin 7.5  per  cent. 

White  blood  cells 8,000 

Polymorphonuclear  leucocytes. ...  74  per  cent. 

Large  mononuclears 8  per  cent. 

Lymphocytes 17  per  cent. 

Transitionals 1  per  cent. 

Spinal  Fluid:     November  11,  1919. 

Pressure Normal  (fluid  dropping  out  of  needle) 

Appearance Perfectly  clear 

Cells 18  lymphocytes 

Globulin Negative 

Wassermann 2  c.c.  1  o.c.  .G  c.c.         .2  c.c. 

Alcohol  antigen Neg.       Nog.       Neg.       Neg. 

Cholesterin  antigen .  Neg.       Neg.       Neg.       Neg. 

Urine  Examination:     November  11,  1919. 

Specific  gravity 1.022 

Reaction Acid 

Color Light  amber 

Precipitate Slight  flocculent 

Albumin None 

Sugar None 

Microscopical  examination. . . .    No  casts,  crystals  or  cells 


136  EPIDEMIC    ENCEPHALITIS 

Blood  Wassermann:     November  13,  1919. 

Alcohol  antigen  Negative 

Cholesterin  antigen Negative 

November  23,  1919.  Patient's  general  condition  has 
improved  much  since  admission.  He  complains  no 
longer  of  insomnia,  stating  that  he  sleeps  normally  at 
night.  During  the  day  he  does  not  feel  stupid  nor  lie  in 
bed  apparently  asleep  as  he  did  during  the  first  week  of 
his  stay  in  the  hospital.  He  now  sits  up  in  a  chair  all 
day  long.  His  vision  is  much  improved.  He  is  able  to  read 
small  newspaper  print  at  a  distance  of  22  inches.  The 
pupils  are  practicallj'-  equal  in  size,  each  measuring  about 
3  milhmeters.  Reaction  to  light  and  on  convergence  is 
normal. 

During  the  patient's  stay  in  the  hospital  his  tempera- 
ture was  generally  normal  except  for  an  admission 
temperature  of  100°. 

SUMMARY 

The  main  findings  on  neurological  examination  were: 
The  mental  stupor,  the  paralysis  of  accommodation  with 
preservation  of  the  pupillary  reflexes,  inequality  of  the 
pupils,  slight  changes  in  the  optic  discs,  absent  ab- 
dominal reflexes  on  the  right,  and  very  slight  general 
spasticity. 

The  course  was  short,  there  being  practically  complete 
recovery  seven  weeks  after  the  onset. 


CHAPTER  XX 


CASE    REPORT   IV 


Miss  M.  S.,  Aged  sixteen.  Garment  worker. 

Admitted  to  the  hospital  September  24,  1919. 

Chief  Complaints:  Drowsiness  for  seven  months; 
muscular  weakness  for  three  months. 

Family  History:  Mother  died  in  childbirth.  Father 
well.  Three  brothers  and  three  sisters  living  and  well. 
Father  has  had  chronic  rheumatism.  No  illness  in  the 
family  similar  to  the  present  one  of  the  patient's.  No 
cancer,  tuberculosis,  insanity  or  other  nervous  disorders. 

Personal  History:  She  is  a  bright,  lively  girl;  a  shirt- 
waist maker.  Drinks  one  or  two  cups  of  coffee  a  day  and 
an  occasional  glass  of  wine.  Has  regular  habits  of  eating 
and  sleeping. 

Previous  History:  As  far  as  she  can  remember  she  has 
never  been  ill  before.  No  accidents  or  operations.  No 
nervous  trouble  of  any  kind. 

Head:     No  headaches. 

Eyes:     Moderately    myopic,     corrected    by    glasses. 

Ears:     Normal;  no  discharge. 

Nose:     She  is  not  subject  to  colds. 

Mouth:  Does  not  remember  having  sore  throat. 
Has  had  some  trouble  with  one  bad  tooth. 

Respiratory    System:     No    cough    or    expectoration. 

Circulatory  System:  No  palpitation,  precordial  pain 
or  distress,  no  dyspnoea  on  exertion  or  swelling  of  the  feet. 

Gastrointestinal:     Appetite   good;   bowels   regular. 

137 


138  EPIDEMIC    ENCEPHALITIS 

Genito-Urinary :  Urine  is  passed  three  to  four  times 
each  day;  no  nocturia. 

Menstruation:  Regular  until  the  onset  of  the  present 
illness.  Periods  began  at  fourteen  and  come  at  30-day 
intervals,  each  one  lasting  five  days.  No  dysmenorrhea 
or  menorrhagia. 

N euro-Muscular:  She  has  never  been  nervous ;  always 
bright  and  happy.  Progressed  well  in  school  work. 

Present  Illness.  Seven  months  ago  as  she  was  working 
in  the  factory  she  suddenly  felt  sick  at  her  stomach  and 
had  a  severe  headache.  There  was  no  vomiting,  chills, 
fever,  cough  or  generahzed  pain.  She  stopped  her  work 
and  went  home  and  was  seen  by  a  physician  who  told 
her  she  had  influenza.  This  illness  lasted  about  two  weeks 
and  was  immediately  followed  by  drowsiness.  She  slept 
most  of  the  time  and  lost  her  usual  vigor.  She  was  easily 
aroused  and  would  eat  normally,  but  after  eating  fell 
into  a  deep  sleep  again.  She  was  sent  to  the  country  for  a 
few  weeks  hoping  she  would  benefit  by  a  change  of  air, 
but  the  condition  continued  the  same. 

Three  months  ago  her  gait  began  to  be  slow  and  shuff- 
ling. She  dragged  her  feet  and  complained  of  easy  fatigue. 
To  raise  the  feet  from  the  ground  took  considerable  effort. 

At  present  she  is  a  little  less  drowsy  but  she  wishes  to 
remain  quietly  in  bed  or  in  a  chair  and  sleeps  a  good  deal 
of  the  time. 

Since  the  onset,  her  menstruation  has  been  irregular. 
She  has  had  only  two  periods  in  the  past  seven  months, 
but  there  has  been  no  headache,  vomiting,  fever  or 
dizziness  since  the  illness  commenced. 

Physical  Examination.  General  Appearance.  A 
medium  sized,  rather  stocky  girl  lying  dorsally  in  bed. 
Her  skin  is  dark,  features  rather  coarse.  The  face  is  ex- 
pressionless except  that  she  smiles  whenever  her  attention 
is  obtained,  though  she  does  not  attempt  to  speak  unless 


STUDIES  OF  SELECTED  CASES        139 

questioned.  Her  voice  is  weak,  high-pitched  and  slight!}- 
tremulous. 

Head:  The  occipital  region  is  rather  flat.  The  head  is 
held  straight  and  motionless.  There  is  no  tenderness  of 
the  skull  to  percussion  or  pressure.  There  are  beads  of 
perspiration  on  the  forehead. 

Eyes:  The  right  palpebral  fissure  is  narrower  than  the 
left.  The  pupils  are  round  and  centrally  placed.  There 
is  no  congestion  oi-  inflammation  of  the  cornea  or 
conjunctivae. 

Ears:     There  is  no  discharge  or  mastoid  tenderness. 

Nose:  The  septum  is  deviated  to  the  left;  otherwise 
the  nose  is  normal. 

Mouth:  The  teeth  are  in  good  condition.  There  is  a 
slight  tremor  of  the  tongue.  The  tonsils  are  large  but  not 
acutely  inflamed. 

Face:  There  is  some  facial  asymmetry  with  flattening 
of  the  left  side,  and  flattening  of  the  left  naso-labial 
furrow. 

Neck:  There  is  a  rather  marked  rigidity  of  the  neck. 
The  chin  can  be  touched  to  the  sternum  but  there  is  a 
spastic  resistance  to  movement.  There  is  no  pain.  Cer- 
vical lymph  nodes  are  not  enlarged.  Thjn'oid  not  palpa- 
ble. No  pulsations  or  masses. 

TJiorax:     Well  developed.  Expansion  good. 

Breasts  are  normal. 

Lungs  are  clear  and  resonant  throughout,  lireath 
sounds  normal. 

Heart:  Normal  in  size,  action  regular.  No  murmurs. 
Sounds  of  good  quality.  Blood  pressure  108-55.  Pulse  72. 

Abdomen  is  flat,  relaxed.  No  tenderness,  masses  or 
signs  of  fluid.  Liver  and  spleen  not  palpable. 

Extremities:     No  deformity  or  edema. 

Superficial  Lymph  Nodes  are  nowhere  enlarged. 

Tem,perature  98.8°.  Weight  1033^^  pounds. 


140  EPIDEMIC    ENCEPHALITIS 

NEUROLOGICAL    EXAMINATION:    OCTOBER  1,  1919. 

Voluntary  Motor  System.  Abnormal  Attitudes 
and  Deformities.  Patient  lies  dorsally  in  bed,  remaining 
in  the  same  attitude  for  long  periods  unless  disturbed. 
Her  eyes  are  partially  closed.  Her  face  is  mask-like  and 
expressionless.  If  she  is  aroused  she  opens  her  eyes  and 
seems  quite  alert,  though  she  does  not  speak  spontane- 
ously, and  answers  questions  promptly  but  with  a  slow, 
monotonous  voice. 

Gait.  Is  slow  and  shuffling,  her  feet  being  scarcely 
lifted  from  the  floor,  her  movements  stiff.  She  is  able  to 
walk  without  assistance. 

Coordination.  There  is  no  Romberg  or  other  sign  of 
equilibratory  incoordination.  The  finger-to-nose,  heel-to- 
knee,  pointing  and  past  pointing  tests  are  performed 
slowly  but  without  deviation.  There  is  no  dysmetria. 
Rapid  pronation  and  supination  of  the  forearms  is  im- 
possible, but  this  is  due  more  to  the  general  spasticity  and 
inability  to  move  quickly  than  to  incoordination. 

Skilled  Acts.  There  is  no  dyspraxia  or  aphasia. 
Speech  is  slow,   monotonous,   weak  and  high-pitched. 

Reflexes: 

Deep  Right  Left 

Jaw 2  2 

Biceps 3  3 

Triceps 2  2 

Radial 3  3 

Ulnar 3  3 

Patellar 3  3 

Achilles 2  2 

Superficial 

Ciliospinal Present  Present 

Upi^er  lateral  abdominal Present  Present 

Lower  lateral  abdominal Present  Present 

Plantar  flexion Present  Present 

Babinski '.  .  .  Absent  Absent 


STUDIES  OF  SELECTED  CASES        141 

Abnormal  Involuntary  Movements.  There  is  a  rather 
fine  tremor  in  the  extended  hands  and  arms,  but  no  other 
involuntary  movements. 

Muscle  Strength.  The  patient  is  able  to  rise  from  the 
recumbent  to  the  sitting  or  standingposition.  The  move- 
ments of  the  neck,  shoulder,  arm,  forearm,  hand,  fingers, 
trunk,  pelvis,  thigh,  leg  and  foot  are  all  equal  on  the  two 
sides,  but  are  everywhere  weaker  than  normal. 

Muscle  Status.  The  muscles  are  well  developed  and 
of  normal  contour.  They  are  hypertonic,  there  being  a 
marked  spasticity.  There  is  much  resistance  to  passive 
movement  which  is  not  constant,  however,  but  shows 
well  the  phenomenon  of  cog-wheel  release. 

Electrical  Reactions  are  normal  to  both  faradic  and 
galvanic  currents.   There  is  no  abnormal  fatiguability. 

Abnormal  Associated  Movements.     Not  tested. 

Nerve  Status.     No  observation. 

General  Sensory.  Touch,  pain,  temperature,  vibra- 
tory, pressure,  muscle  tendon  sense  and  stereognostic 
perception  are  normal. 

Cranial  Nerves  and  Head.  Olfactory  Nerve  and 
Nose:     The  sense  of  smell  is  normal. 

Optic  and  Oculomotor  Apparatus.  Visual  acuity, 
roughly  tested,  is  normal.  There  is  no  contraction  of  the 
visual  fields.  Ej^egrounds :  There  is  slight  blurring  of  the 
upper  and  lower  margins  of  the  optic  discs  on  the  right 
side.  The  physiological  cup  is  absent.  The  vessels  are 
slightly  tortuous.  There  are  no  hemorrhages.  The  pupils 
are  equal,  circular  and  centrally  placed.  Thej^  react 
actively  to  light  and  on  accommodation.  The  right  pal- 
pebral fissure  is  narrower  than  the  left.  There  is  no 
evident  exophthalmos,  enophthalmos  or  strabismus. 
Conjugated  eye  movements  are  normal.  In  extreme 
lateral  positions  there  is  a  slight  transient  nystagmus. 


142  EPIDEMIC    ENCEPHALITIS 

Acoustic  Nerve  and  Ear.  Hearing  is  normal.  Air  con- 
duction is  greater  than  bone  conduction  on  each  side. 

Trigeminus  Nerve  and  Mouth.  The  jaws  can  be  moved 
normally  in  all  directions.  Corneal  reflexes  are  present. 
There  is  no  facial  anaesthesia. 

Facial  Nerve  and  Face.  There  is  a  flattening  of  the 
left  side  of  the  face  with  partial  obliteration  of  the  naso- 
labial fold  and  depression  of  the  left  corner  of  the  mouth. 
There  is  no  evident  involvement  of  the  upper  face. 

Glossopharyngeus  and  Vagus  Nerves,  Pharynx  and 
Larynx.  The  uvula  is  in  the  median  position.  The 
palatal  and  pharyngeal  reflexes  are  present.  Swallowing, 
respiratory  and  cardiac  action  are  normal. 

Spinal  Accessory  Nerve.  The  sternomastoid  and  tra- 
'  pezius  muscles  are  normal. 

Hypoglossus  Nerve  and  Tongue.  There  is  a  constant 
slight  tremor.  The  tongue  is  protruded  in  the  midline 
and  movements  in  all  directions  are  normal. 

SUMMARY    OF    NEUROLOGICAL    EXAMINATION 

1.  Mental  inertia  and  somnolence. 

2.  General  rigidity  of  musculatiu'e  with  marked  cog- 
wheel resistance  to  passive  movements. 

3.  Retardation  of  active  movements  with  some  ten- 
dency to  catatonia. 

4.  Mask-like  expression  of  face  with  weakness  on  the 
left  side. 

LABORATORY  EXAMINATIONS 

Blood  Count:    September  24,  1919. 

Red  blood  cells 5,600,000 

Hemoglobin 85  per  cent. 

White  blood  cells 7,700 

Polymorphonuclear  leucocytes 48  per  cent. 

Lymphocytes 48  per  cent. 

Eosinophils 4  per  cent. 


STUDIES  OF  SELECTED  CASP:S        143 

Blood  Wassermann:    September  25,  1919. 

Alcohol  antigen Negative 

Cholesterin  antigen Negative 

Blood  Urea:    September  25,  1919. 

0.3  gram  per  liter. 

Lumbar  Puncture:     September  25,  1919. 

15  c.c.  of  clear  colorless  fluid  removed  under  definitely  increased 
pressure,  a  steady  stream  spurting  about  one  inch  from,  the 
needle  with  noticeal^le  pulsations. 

Globulin Negative 

Cells 4  lymphocytes 

Wassermann 2  c.c.      1  c.c.      .6  c.c.    .2  c.c. 

Alcohol  antigen Neg.       Neg.       Neg.       Neg. 

Cholesterin  antigen.  Neg.       Neg.       Neg.       Neg. 

Colloidal  gold 0010000000 

Culture Sterile 

Urine  Examination:    September  25,  1919. 

Specific  gravity 1.021 

Reaction Acid 

Albumin None 

Sugar None 

Microscopical  examination ....    Few  squamous  epithelial  cells 

No  casts  or  crystals 

Lumbar  Puncture:     October  2,  1919. 

15  c.c.  of  spinal  fluid  removed;  first  blood-tinged,  then  clear 
and  colorless,  under  no  increased  pressure. 

Culture Sterile 

Glucose  Tolerance  Test:     October  6,  1919. 

78  grams  of  gluco.se  (1.75  grams  of  glucose  per  kilo  of  body 
weight). 

Blood  Sugar  Urine 

Fasting 88  grams  per  liter     No  sugar 

3  hours  after  glucose. . .   .94  grams  per  liter     2  hrs.  after  glucose, 

no  sugar 
4  hrs.  after  glucose, 
very  slight  reduc- 
tion 
6  hrs.  after  glucose, 
no  sugar 


144  EPIDEMIC    ENCEPHALITIS 

Lumbar  Puncture :     October  7,  1919. 

Amount 10  c.c. 

Pressure Not  increased 

Appearance Clear,  colorless 

Globulin Negative 

Cells 2  lymphocytes 

Culture Sterile 

Clinical  Notes:  October  10,  1919:  Patient  is  dis- 
charged to-daj''  in  practically  the  same  condition  as  on 
admission  to  the  hospital. 

November  17,  1919.  Miss  S.  is  readmitted  to  the 
hospital  to-day  and  states  that  she  remained  practicallj'^ 
the  same  for  two  weeks  after  discharge;  but  at  the  end 
of  this  time  there  appeared  a  tremor  in  the  right  hand. 
It  was  very  slight  at  first  but  in  a  week  or  ten  days  be- 
came quite  pronounced.  At  times  there  would  also  be  a 
trembling  of  the  right  leg.  The  tremor  varies  in  intensity 
but  is  present  most  of  the  time  while  she  is  awake, 
ceasing  only  on  voluntary  movement  or  when  the 
trembling  hand  is  held  by  the  steady  one.  The  tremor  is 
aggravated  by  any  excitement.  She  has  also  noted 
difficulty  in  standing.  There  is  not  much  difference  in 
walking,  but  on  attempting  to  stand  she  feels  as  though 
she  would  fall  backward  and  it  is  necessary  for  her  to 
hold  on  to  something  for  support.  For  the  past  two  weeks 
she  has  had  a  constant  excessive  secretion  of  saliva  which 
has  been  quite  annoying.  It  runs  out  of  her  mouth  at 
night  if  she  is  lying  on  her  side.  There  has  been  no 
increased  nasal  secretion  or  excessive  perspiration.  She 
has  had  no  pain,  but  her  arm  gets  very  fatigued  from  the 
constant  tremor. 

Spinal  Puncture:     November  19,  1919. 

Appearance Perfectly  clear 

Pressure Normal,  the  fluid  flowing  from  the 

needle  drop  by  drop 

Cells 4  lymphocytes 

Globulin Negative 


STUDIES  OF  SELECTED  CASES 


145 


Fig.  27.  Fig.  28. 

Fig.  27.— Case  IV.     Stiff,  Slightly  Flexed,  Statuesque  Attitude, 

with  Tendency  to  Fall  Backwards. 

Fig.  28. — Case  IV.     Parkinsonian  Facies,  Attitude  and  Tremor 

of  Right  Hand. 


146  EPIDEMIC    ENCEPHALITIS 

NEUROLOGICAL    FINDINGS:    NOVEMBER    22,    1919. 

The  patient  now  presents  a  typical  picture  of  a  Parkin- 
son's disease  showine;  the  four  cardinal  symptoms: 

1.  Muscular  rigidity. 

2.  Impairment  and  retardation  of  active  movement. 

3.  Characteristic  tremor. 

4.  Difficulty  in  maintaining  balance  and  character- 
istic modifications  of  gait. 

Besides  these  there  are  also  added  other  symptoms, 
namely,  uncontrolled  smiling,  left  facial  weakness 
and  mental  alteration.  The  muscular  rigidity  is  quite 
marked,  especially  in  the  back,  extremities  and  face. 
The  head  and  shoulders  are  not  inclined  forward,  but 
the  back  is  held  in  a  rigid,  poker-like  fashion.  The  arms 
are  slightly  abducted  at  the  shoulders,  and  flexed  at  the 
elbows.  The  wrists  are  over-extended  and  the  fingers 
slightly  flexed  at  the  metacarpo-phalangeal  joint.  On 
standing  there  is  very  little,  if  any,  flexion  at  the  hip 
or  knee-joint.  The  features  are  fixed  and  expressionless, 
except  for  an  uncontrolled,  stereotyped  smile  provoked 
when  anyone  attracts  her  attention.  Voluntary  move- 
ments are  performed  slowly  and  stiffly  and  there  is  a 
marked  resistance  to  passive  movements  with  irregular, 
jerky  release.  The  tremor  is  most  pronounced  in  the 
right  hand  but  is  present  in  the  right  leg  and  to  a  less 
extent  in  the  left  hand.  It  is  of  fairly  large  amplitude 
and  relatively  slow.  It  involves  the  whole  forearm  and 
arm,  and  is  a  true  shaking  with  little  or  no  pill-rolling 
movement  of  the  thumb  and  fingers.  When  excited, 
there  is  a  similar  shaking  of  the  right  leg.  The  tremor  is 
stopped  by  active  movement. 

The  walking  is  slow,  shuffling  and  unsteady,  with  a 
constant  tendency  to  fall  backward  with  a  suppression 
of  all  automatic  associated  movements. 


STUDIES  OF  SELECTED  CASES        147 

The  added  features,  smiling,  facial  weakness  and 
mental  alteration,  do  not  belong  to  the  Parkinson's 
picture,  but  are  due  to  other  lesions.  The  uncontrolled 


Fig.  29. — C.\se   IV.     Uncontrollable   Smiling   and    Weakness   of 
Left  Side  of  Face. 

smiling  is  due  to  injury-  of  the  fronto-thalamic  fibers. 
The  mental  slowness  and  lack  of  spontaneity  are  char- 
acteri.stic  of  epidemic  encephalitis.  The  facial  weakness 
on  the  left  side  at  her  last  admission  was  said  to  have 


148  EPIDEMIC    ENCErHALITIS 

been  noted  before  the  present  illness  commenced;  but 
it  seems  to  have  increased  during  the  past  month. 

SUMMARY 

The  onset  was  that  of  an  acute  infection  which  was  said 
to  be  influenza.  Two  weeks  later  drowsiness  appeared, 
and  then  a  loss  of  strength  and  vigor.  Four  months  after 
the  onset  the  gait  became  slow  and  shuffling.  Active 
movements  were  retarded  and  there  was  general  muscu- 
lar rigidity.  Eight  months  after  the  illness  commenced, 
tremor  and  difficulty  in  maintaining  balance  developed. 
The  Parkinson  sj^ndrome  was  complete. 


CHAPTER  XXI 


CASE   REPORT  V 


Mr.  M.  F.,  Aged  fifty-three.  Married.  Tailor  by 
occupation. 

Admitted  to  the  hospital  October  8,  1919. 

Chief  Coni-plaints.  Weakness,  drowsiness,  pains  in 
both  eyes,  duration  three  weeks. 

Family  History.  Father  died  at  75,  mother  at  70. 
For  some  years  before  her  death  the  mother  had  a  tremor 
of  the  hands  which  prevented  her  from  picking  up  things 
easily.  One  brother  is  living  and  well.  One  sister  is  living 
and  well  in  Russia.  No  insanity,  nervousness  or  chronic 
diseases  in  the  family. 

Personal  History.  Patient  has  been  married  thirty 
3'ears;  his  wife  and  three  sons  and  two  daughters  are 
living  and  well.  His  habits  are  good.  He  uses  alcoholic 
stimulants  in  moderation  occasionally.  Appetite,  until 
the  onset  of  the  present  illness  has  been  good.  Bowels 
regular. 

Past  History.  He  was  well  all  his  life  until  two  years 
ago  when  he  had  a  short  attack  of  nervousness.  He  and 
his  famil}^  moved  to  the  Bronx.  He  did  not  like  the  place 
and  was  unable  to  sleep.  He  used  to  get  out  of  bed  a  dozen 
times  a  night  and  pace  the  floor.  His  physician  advised 
him  to  move,  and  after  doing  so  all  his  nervousness 
disappeared.  He  has  been  well  ever  since. 

Present  Ilh^ess.  On  about  September  15th  he  began 
to  have  shooting  pains  in  the  eyes.  He  continued  to  work 
for  two  daj's  but  on  the  third  day  they  were  so  severe 

149 


150  EPIDEMIC    ENCEPHALITIS 

that  he  had  to  remain  at  home.  He  then  became  weak 
and  drowsy.  His  physician  prescribed  some  eye  drops, 
but  he  soon  became  more  drowsy  and  unable  to  open  his 
eyes,  so  the  drops  were  discontinued.  As  the  drowsiness 
became  more  marked  the  pain  in  his  eyes  disappeared, 
though  he  still  was  unable  to  open  his  eyelids  fully. 

On  October  3rd,  while  walking  across  the  floor  he 
suddenl}^  fell  and  was  unable  to  get  up  or  to  speak  dis- 
tinctly. By  pounding  on  the  floor  he  aroused  the  family, 
who  got  him  into  bed.  When  they  arrived  he  could  only 
speak  in  a  whisper  and  indistinctly.  The  difficulty  in 
speech  has  continued  until  to-daj-  when  it  became  much 
worse. 

This  morning,  before  admission  to  the  hospital,  at 
about  4  A.M.  he  awoke  and  found  he  was  unable  to  move 
his  jaw.  He  could  not  talk  or  swallow.  About  five  hours 
later  he  was  able  to  talk  a  little  though  ver}^  indistinctly, 
but  was  still  unable  to  move  his  jaw,  his  mouth  remaining 
partially  open.  He  has  a  slight  frontal  headache;  has  had 
no  vertigo  or  convulsions,  or  clouding  of  consciousness. 

PHYSICAL    EXAMINATION 

General  Appearance.  A  rather  thin,  elderly  man, 
lying  partially  propped  up  in  bed,  apparently  in  deep 
stupor.  His  head  is  retracted,  his  knees  flexed.  He  may 
be  aroused  by  repeated  questioning.  His  skin  is  dry,  cool 
and  clear.  Superficial  lymph  nodes  are  not  palpably 
enlarged. 

Head  is  symmetrical.  There  are  no  tender  areas. 

Eyes  are  partially  covered  by  drooping  eyelids  and  are 
staring  directl}^  forward.  There  is  no  sign^of  corneal  or 
conjunctival  inflammation. 

Ears  and  Nose  are  negative  to  external  examination. 


STUDIES  OF  SELECTED  CASES        151 

Mouth  is  held  partially  open,  the  lower  jaw  being 
rigid,  so  that  it  is  impossible  to  get  a  clear  vision  of  the 
throat,  but  there  appear  to  be  patches  of  dry  mucus  on 
the  posterior  wall  of  the  pharynx.  The  tongue  is  dry  and 


coated.  The  teeth  are  in  poor  condition.  The  gums  show 
moderate  pyorrhea. 

Neck  is  stiff  and  resists  bending  forward  or  laterallj^ 
There  is  no  thyroid  enlargement. 


152  EPIDEMIC    ENCEPHALITIS 

Chest  is  rather  poorly  developed;  expansion  poor  but 
symmetrical  and  equal. 

Lungs:  There  is  no  dullness.  The  voice  and  breath 
sounds  are  normal  but  there  are  many  loud  gurgling 
noises  both  on  inspiration  and  expiration  transmitted 
from  the  throat. 

Heart  is  normal  to  percussion.  The  apex  impulse  is 
in  the  fourth  space,  9)-2  centimeters  to  the  left  of  the 
midline.  The  sounds  are  of  good  quality.  There  are  no 
murmurs.  Blood  pressure  140-100.  The  pulse  is  regular, 
full,  of  moderate  tension  with  a  slight  thickening  of  the 
vessel  wall.  Rate  96. 

Abdomen  is  held  rather  rigidly.  There  are  no  masses, 
tenderness,  or  signs  of  fluid.  The  spleen  and  liver  are  not 
felt. 

Extremities:     There  is  no  edema  or  deformitj-. 

Rectal  examination  is  negative. 

NEUROLOGICAL    EXAMINATION:       OCTOBER   10,   1919 

Voluntary  Motor  System.  A  hnormal  A  ttitudes  and 
Deformities.  Patient  is  lying  propped  up  in  bed  with 
mouth  open,  mask-like,  emotionless  face,  eyes  partially 
closed,  staring  directly  forward,  giving  an  extremely 
expressionless  facial  appearance. 

Gait.     He  is  unable  to  stand  or  walk. 

Coordination.  Muscular  movements  are  carried  out 
in  a  very  slow,  stiff,  deliberate  manner.  He  is  able  to 
touch  his  nose  with  the  pointer  finger  of  either  hand  with- 
out uncertainty  of  position.  Heel-to-knee  tests  are  less 
well  performed,  and  show  weakness,  stiffness  and  ataxia. 

Skilled  Acts.  Pronation  and  supination  of  the  fore- 
arms are  slowly,  stiffly  and  imperfectly  carried  out. 
There  is  no  aphasia  or  apraxia.   Speech  is  drawling, 


STUDIES  OF  SELECTED  CASES 


153 


monotonous,    almost    unintelligible    due    to    defective 
articulation. 

Reflexes.     The  jaw,   pectoral,   biceps,  triceps,  radial, 
ulnar,  patellar,  and  Achilles  reflexes  are  all  present  and 


Fig.  31. — Case  \'. 


moderately  active.  The  right  biceps,  knee  and  ankle 
jerks  are  more  active  than  those  on  the  left  side.  The 
abdominal  reflexes  are  active.  There  is  no  Babinski  or 


154  EPIDEMIC    ENCEPHALITIS 

modifications,  but  a  spurious  ankle  clonus  is  elicited  on 
the  right  side. 

Abnormal  Involuntary  Movements.  There  are  no 
abnormal  involuntary  movements  except  that  of  the 
tongue,  which  shows  a  constant  marked  tremor,  mainly 
of  the  protrusion  type. 

Muscle  strength  is  very  difficult  to  test  because  of 
lack  of  cooperation,  but  the  grip  seems  weaker  in  the 
right  hand.  He  is  unable  voluntarily  to  sit  up  in  bed,  and 
all  muscular  movement  shows  decided  weakness.  There 
is  a  decided  rigidity  of  all  the  muscles,  but  especially 
those  of  the  extremities.  Passive  movements  of  all  the 
extremities  are  inhibited  by  extreme  rigidity  which, 
however,  shows  some  tendency  to  cog-wheel  release. 
There  is  decided  flexibilitas  cerea,  the  limbs  remaining 
for  some  time  in  any  position  in  which  they  are  placed. 
General  Sensory.  Sensory  examination  is  difficult, 
but  there  seems  to  be  no  gross  anaesthesia  to  touch  or 
pain.  Sense  of  position  of  his  feet  seems  to  be  impaired. 
There  is  diminution  in  corneal  sensibility  on  either  side. 

Cranial  Nerves.  Olfactory  Nerve  and  Nose.  Smell 
is  probably  normal. 

Optic  and  Oculomotor  Apparatus.  Visual  acuity  is 
difficult  to  test,  but  he  can  tell  the  number  of  fingers  held 
three  feet  away  from  each  eye.  The  pupils  are  quite 
regular,  each  about  3  millimeters  in  diameter.  The 
reaction  to  light  is  present,  but  a  little  sluggish  in  each 
eye.  It  is  impossible  to  tell  definitely  about  reaction  to 
accommodation,  on  account  of  the  ptosis  and  inability 
to  converge.  There  is  double  ptosis,  the  palpebral  fis- 
sures measuring  5  millimeters  on  each  side.  He  is  unable 
to  open  or  voluntarily  to  close  the  eyes,  although  the  blink- 
ing reflex  is  still  present.  There  is  no  evident  alteration 
in  the  anteroposterior  position  of  the  eyeballs. 


STUDIES  OF  SELECTED  CASES        15.5 

Both  eyes  appear  directed  straight  forward.  He  is 
unable  to  move  either  eye  upward  or  downward,  and 
refuses  to  look  to  either  side  on  command,  but  will 
follow  with  his  eyes  an  object  moved  laterally  when 
directed  to  do  so,  so  that  there  is  conjugate  lateral 
excursion  of  the  eyes  which,  however,  does  not  extend 
to  the  normal  degree. 

Fundi :  There  is  slight  haziness  of  the  margins  of  the 
optic  disc  of  the  left  eye.  The  vessels  appear  normal. 
There  are  no  retinal  hemorrhages.  The  right  fundus  is 
normal. 

Acoustic  Nerve  and  Ear.     Hearing  is  normal. 

Trigeminus  Nerve  and  Mouth.  'The  moutli  is  held 
rigidly  in  the  half-open  position,  and  he  seems  unable 
voluntarily  to  open  or  close  it.  He  cannot  move  the  jaw 
laterally  or  protrude  it.  It  does  move  somewhat,  how- 
ever, when  he  attempts  to  speak.  The  jaw  jerk  is  active 
on  each  side.  There  seems  to  be  no  definite  sensory  dis- 
turbance in  the  fifth  nerve  area  except  for  the  hypaes- 
thesia  of  the  cornea. 

Facial  Nerve  and  Face.  There  is  a  decided  mask-like 
expression  of  the  face  and  an  inability  to  retract  the 
corners  of  the  mouth.  The  left  corner  of  the  mouth  is 
slightly  lower  than  the  right.  Movement  of  the  lips  is 
present  on  attempting  to  speak,  though  it  is  imperfect. 

Glossopharyngeus  and  Vagus  Nerves,  Pharynx  and 
Larynx.  Swallowing  is  difficult  and  almost  impossible. 
A  satisfactory  view  of  the  pharynx  cannot  be  obtained 
because  of  the  rigidity  of  the  jaw,  but  it  appears  to  be 
normal.  The  pharyngeal  reflex  is  hyperactive. 

Hypoglossus  Nerve  and  Tongue.  The  tongue  cannot 
be  protruded  beyond  the  lips,  but  shows  a  definite 
protrusion  to  the  right  and  an  inability  to  move  it  as  far 
to  the  left  as  to  the  right.  There  is  a  constant  coarse 
tremor  which  is  not  fibrillary. 


156  EPIDEMIC    ENCEPHALITIS 

LABORATORY  EXAMINATIONS   AND    CLINICAL   NOTES 

Spinal  Puncture:     Octobers,  1919. 

Pressure Considerably  increased.  First  5  c.c. 

spurted  out  of  the  needle. 

Amount 25  c.c. 

Appearance Perfectly  clear 

Cells 9  lymphocytes 

Globulin Faintly  po.sitive 

Culture Sterile 

Wassermann 2  c.c.      1  c.c.      .6  c.c.      .2  c.c. 

Alcohol  antigen Neg.       Neg.       Neg.       Neg. 

Cholesterin  antigen. ..  Neg.       Neg.       Neg.       Neg. 

Blood  Examination:     October  8,  1919. 

Blood  urea 13  grams  per  liter 

Blood  Wassermann:     Octobers,  1919. 

Alcohol  antigen Negative 

Cholesterin  antigen Negative 

Blood  Culture:     October  S,  1919. 

Steiile 

Blood  Count:     October  S,  1919. 

Red  blood  cells 5,600.000 

Hemoglobin 85  per  cent. 

White  blood  cells 1 1,000 

Polymorphonuclear  leucocytes. .  85  per  cent. 

Urine  Examination:     October  S,  1919. 

Specific  gravity 1.022 

Reaction Acid 

Color Amber 

Albumin None 

Glucose None 

Microscopical  examination No  casts,  crys- 
tals or  cells 
Spinal  Puncture:     October  11,  1919. 

20  c.c.  of  slightly  blood-tinged  fluid  removed  under  no  in- 
creased pressure.  Search  was  made  for  tubercle  bacilli  but  none 
were  found. 


STUDIES  OF  SELECTED  CASES 


157 


October  11,  1919.  Ankle  clonus  has  disappeared. 
Spasticity  is  a  little  less  marked;  speech  a  little  clearer. 
Slight  divergent  strabismus,  but  lateral  ocular  move- 
ments are  still  present.  Mental  functions  are  much  clearer 
than  his  general  condition  would  lead  one  to  expect 
He  endeavors  to  answer  questions  quickh'. 


VdiifA 

'" 

0«,  ol  ticnik 

e 

9 

ao 

11 

12 

13 

1 

Do)  of  liiHItl 

21 

22 

23 

25 

26 

,     37              1 

Her  0/  D;       i 

8/i!*'»o  1 

h» 

i 

,m 

«  t 

,1 

*  t\iX 

•  r 

It. 

r;»H 

r* 

•  lf|a 

1 

rl,.J,^^y 

"i"!' 

'I^i 

Pl^. 

To-.- 

■■((■!    ■ 

. 

;!; 

■'■ 

"^ 

■ 

■    \  1 

lidl 

170 
160 
190 
140 
130 
ItO 
110 
100 
90 
90 
70 
CO 
SO 
40 

108-  - 

■  1  -  ; 

.     ! : 

,»• 

' 

;i  :  : 

'I' 

. 

.1 

,..| 

; 

I:  ■; 

: 

; 

- 

• 
• 

; 

■ 

" 

■1  • 

: 

■ 

: 

;i; 

.:  -1- 

'-    - 

; 

■ 

!, 

:|- 

; 
■1  '. 

\'\-.A 

■ 

■■■■ 

- 

; ; : 

-108' 

;;; 

■|: 

:  : 

'-\ 

: 

'■_  \ 

; 

: 

:  : 

.  ■ 

'■A  .'■' 

,.-■% 

'  M 

'   i:!  : 

■\ 

■ 

: 

/: 

i  ..,.1 

100- 

-m : 

• 

\ 

i- 

">?(i 

J^t^ 

> 

"S 

;_. — . — 100- 
w 

-sfiA 

; 

'Y 

^ 

:i:| 

:  : 

::|: 

ii:i: 

:'■ 

: 

; 

■1;  . 

\          / 

11: 

m- 

;j- 

: 

-■\ 

»T-- 

:i: 

:[;: 

: 

; : 

i  'i  ■ 
•i  -j  '■ 

:|  - 

:  .i- 

:i 

: 

:l;j: 

•    I- 

■ 

T 

■1 : 

';  : 

■.■.\: 
:    1  : 

\\'  ; 

■   :|:i: 

':  '■^\ 

:  'I:!: 

:  ■'  :!: 

_Ri 

tfvoh. 

«• 

tfi^i 

w 

mtti>» 

j«5W«itr,_ 

^ 

Ji^^"| 

xs 

at 

i. 

i^ 

,  _ 

5^-iaJ 

IL 

L 

l1 

Fig.  32. — Case  V.     Temperature  and  Pulse  Chart  During  Final 

Week  of  Illness. 

Temperature        Pulse 


October  12,  1919.  As  the  patient  is  unable  to  swallow, 
it  is  necessary  to  feed  him  by  lavage.  Since  admission 
there  has  been  a  general  decrease  in  muscular  strength, 
a  disappearance  of  the  catatonia  and  a  diminution  of 
the  general  spasticity.  He  is  able  to  move  his  jaw  and 
there  is  a  very  slight  improvement  in  his  speech.   His 


158  EPIDEMIC    ENCEPHALITIS 

understanding  is  apparently  normal.  There  is  conjugate 
deviation  to  the  left. 

October  13,  1919.  Laryngeal  Examination.  There 
seems  to  be  no  paralysis.  The  cords  do  not  move  with 
respiration,  and  as  there  is  no  attempt  made  to  pho- 
nate  the  cords  are  semi-abducted  and  show  fibrillary 
twitchings. 

October  13,  1919.  This  morning  the  condition  became 
very  much  worse.  The  hps  are  markedly  cyanotic;  there 
is  a  coarse  gurgling  in  the  throat,  respiratorial  rate  is 
increased  and  rather  shallow.  The  pulse  is  slow  (40)  full 
and  well  sustained.  Pulse  and  respirations  are  absolutely 
synchronous  in  rate,  each  being  40.  The  blood  pressure 
has  risen  to  170-110. 

October  14,  1919.  During  the  past  24  hours  the  pa- 
tient's general  condition  gradually  became  worse.  Cya- 
nosis became  more  marked.  The  respiratory  rate  rose 
to  about  52,  his  pulse  continuing  in  the  60's  until  shortly 
before  death  when  it  rose  to  108,  death  apparently 
resulting  from  respiratory  paralysis. 

The  temperature  during  his  stay  in  the  hospital  was 
never  over  100.6°.  The  pulse  varied  from  40  to  108. 

AUTOPSY,   OCTOBER   14,    1919 

(Drs.  Meleny  and  Pappenheimer)  7  hours  p.m. 

The  body  is  that  of  a  middle-aged  white  man  consid- 
erably emaciated,  measuring  170  centimeters  in  length. 
Moderate  rigor  mortis.  Slight  lividity  of  the  dependent 
parts.  The  skin  is  pale,  the  hair  distribution  normal. 
There  is  an  abundant  amount  of  gray  hair  on  the  scalp. 
There  is  a  small  abrasion  of  the  skin  over  the  sacrum. 
No  edema.  The  conjunctivae  are  pale;  no  petechiae.  No 
excretion  from  the  nose,  ears  or  mouth.  Teeth  are  in  a 


STUDIES    OF    SELECTED    CASES  159 

fair  state  of  preservation  except  for  one  upper  biscupid 
which  is  badly  carious.  No  bridgework.  The  tongue  is 
heavily  coated  with  a  thick  white  fur.  There  are  no  en- 
larged lymph  ghintls.  The  alxlonien  is  protuberant 
apparently  from  gas  in  the  intestines.  There  is  a  small 
pedunculated  tumor  on  the  outer  aspect  of  the  right 
thigh,  apparently  a  lipoma. 

Abdomen:  The  panniculus  is  1  centimeter  in  thick- 
ness. The  large  intestine  is  alternately  distended  with  gas 
and  tightly  contracted  in  areas  about  15  centimeters 
long.  There  are  old,  firm,  fi])ious  adhesions  between  the 
under  surface  of  the  liver,  stomacii  and  omentum  and 
between  the  omentum  and  transverse  colon;  also  between 
the  ascending  colon  and  the  lateral  abdominal  wall. 
The  appendix  is  atrophic,  6  centimeters  long,  not  ad- 
herent. There  is  no  free  fluid  in  the  abdominal  cavitj' 
nor  any  evidence  of  peritonitis.  There  is  irregular  con- 
gestion of  the  large  vessels  in  the  mesentery.  The  stom- 
ach is  greatly  relaxed  and  partially  filled  with  fluid.  The 
liver  extends  1  centimeter  below  the  costal  margin  on 
each  side  of  the  midline,  but  just  reaches  the  costal 
margin  in  the  right  midclavicular  line.  The  spleen  ex- 
tends to  2  centimeters  above  the  costal  margin.  The 
bladder  is  contracted;  the  diaphragm  on  the  right  side 
is  at  the  level  of  the  fifth  rib;  on  the  left  side  at  the  fifth 
space. 

Thorax:  The  mediastinum  is  apparentlj^  normal.  The 
pericardial  cavity  contains  5  c.c.  of  clear  fluid.  No  pericar- 
ditis. The  pleural  cavities  are  dry.  Both  lungs  are  adher- 
ent to  the  chest  wall  at  their  apices  by  very  firm  fibrous 
adhesions. 

Heart:  Weighs  290  grams.  Not  apparently  enlarged. 
In  normal  position;  all  cavities  and  valves  appear  normal. 
The  endocardium  has  a  few  fibrous  streaks  in  tlu*  right 


160  EPIDEMIC    ENCEPHALITIS 

ventricle;  otherwise  it  is  normal.  The  myocardium  ap- 
pears normal.  Just  above  the  aortic  valve  at  the  insertion 
of  the  cusps  there  are  thin,  atheromatous  plaques.  These 
are  also  present  in  the  coronary  arteries  and  in  the  begin- 
ning of  the  aorta. 

The  Aorta  is  normal,  elastic,  has  a  few  atheromatous 
plaques  along  its  course. 

Left  Lung:  Weighs  470  grams,  very  firm,  fibrous 
adhesions  present  at  the  apex  with  contraction  of  the 
lung  tissue  between  them.  The  lung  surface  is  gray  in 
color  with  large  anthracotic  pigment.  Posteriorly  there 
is  some  congestion.  There  is  apparently  considerable 
emphysema.  The  lung  does  not  collapse  but  is  entirelj' 
air-containing.  On  section  there  is  moderate  congestion 
seen  posteriorly,  but  practically  no  edema.  The  bronchi 
are  considerably  congested  and  contain  a  very  small 
amount  of  fluid.  The  bronchial  lymph  nodes  are  small, 
the  vessels  normal. 

Right  Lung:  Weighs  530  grams.  The  adhesions  are 
similar  to  those  on  the  left,  but  with  more  contraction 
at  the  apex  and  just  beneath  the  surface  an  abscess 
cavity  containing  thick  brownish  yellow  pus  is  opened, 
having-  a  thin  fibrous  wall.  No  connection  with  the 
bronchus  is  demonstrated.  Scattered  over  the  upper 
and  lower  lobes  are  raised  areas  about  2  centimeters  in 
diameter  of  the  same  color  as  the  rest  of  the  lung,  but 
slightly  firmer.  Posteriorly  there  is  congestion.  On  sec- 
tion the  small  bronchi  contain  thick  yellow  pus.  The 
large  ones  contain  thin  mucopurulent  fluid.  No  other 
abscesses  are  encountered.  The  firm  raised  areas  are  seen 
to  be  masses  of  minute  gray  nodules  1  millimeter  in 
diameter,  apparently  tubercles.  The  bronchial  lymph 
nodes  and  vessels  are  unaltered. 

Thymus:     No  tissue  demonsti-able. 


STUDIES  OF  SELECTED  CASES        161 

Liver:  Weighs  1460  grams.  Color  is  dark  red  on  the 
surface  and  reddish  brown  on  section.  The  lobules  are 
reddish  brown  at  their  centers,  brown  at  the  periphery. 
There  is  apparently  a  moderate  degree  of  chronic  passive 
congestion.  There  is  a  slight  increase  of  fibrous  tissue; 
the  vessels  appear  noi-mal. 

Gall-bladder:  It  is  surrounded  b}'  thick  fibrous  ad- 
hesions which  partially  constrict  it.  It  is  only  partially 
filled  with  thick,  olive  colored  bile.  The  wall  and  the 
mucosa  appear  normal.  The  ducts  are  patent. 

Spleen:  Weighs  110  grams.  The  capsule  is  wrinkled. 
The  color  is  blue;  consistency  flabby.  On  section  it  has  a 
dark  reddish  brown  color.  It  is  moderatel.y  firm.  The 
corpuscles  are  indistinct.  The  trabeculae  ai'e  normally 
prominent. 

Adrenals  are  apparently  unaltered. 

Kidneys  together  weigh  360  grams.  They  are  equal  in 
size,  somewhat  flabb3^  The  capsule  strips  easilj''  leaving 
a  surface  of  grayish  red  with  stellate  veins  congested. 
On  section  it  shows  considerable  congestion.  The  stria- 
tions  are  prominent.  The  glomeruli  appear  normal.  The 
cortex  averages  6  millimeters  in  thickness.  The  pelvis 
and  ureters  are  slightly  congested. 

Bladder  is  contracted.  It  contains  25  c.c.  of  cloudy 
yellow  urine.  There  are  a  few  submucous  petechial 
hemorrhages. 

Prostate:  Both  lateral  lobes  are  considerably  enlarged 
and  equal  in  size,  each  being  2.5  millimeters  broad  and  2 
centimeters  high.  On  section  each  lobe  seems  to  contain 
adenomata.  The  middle  lobe  is  not  enlarged. 

Testicles  are  normal. 

Gastrointestinal  Tract:  The  esophagus  is  normal.  The 
stomach  is  greatly  enlarged,  containing  greenish  brown 
fluid.  The  mucosa  is  pale  and  considerably  digested.  On 


162  EPIDEMIC    ENCEPHALITIS 

the  posterior  surface,  about  the  middle,  is  a  submu- 
cous hemorrhage  1  centimeter  in  diameter,  but  no  scar 
or  ulcer  beneath  it.  The  duodenum  shows  many  sub- 
mucous hemorrhages.  The  jejunum  and  ilium  are  normal. 
The  large  intestine  is  normal.  The  rectum  shows  general 
congestion. 

Organs  of  the  Mouth  and  Neck:     Nothing  remarkable. 

Head:  The  brain  is  considerably  congested.  The 
meninges  slightly  congested.  No  gross  abnormalities 
found  on  section.- The  sinuses  and  middle  ear  are  negative. 

Spinal  cord  is  grossly  normal  except  for  congestion. 

Microscopical.  Examination  of  Nerve  Tissue.  The 
pia  mater  over  the  surface  of  both  brain  and  cord  is 
congested.  There  are  a  few  hemorrhages  between  the  pial 
layers  but  no  cellular  infiltration.  Sections  of  the  cortex 
show  a  very  slight  degree  of  alteration  but  no  distinct 
change  in  the  pyramidal  cells.  There  is  distinct  vascular 
congestion  which  is  more  pronounced  in  the  deeper 
layers.  In  the  internal  capsule  and  deep  white  matter 
there  are  localized  areas  of  cellular  infiltration.  The  cells 
forming  these  accumulations  are  largely  ameboid  glia 
cells.  In  the  optic  thalamus  there  is  extreme  capillary 
congestion,  and  in  some  portions  of  the  internal  capsule 
bordering  on  the  thalamus  there  are  areas  showing 
diffuse  cellular  accumulation.  Many  of  the  thalamic  cells 
are  swollen  and  misshapen.  The  nuclei  appear  normal 
but  are  eccentrically  placed.  A  good  deal  of  fat  pigment 
is  noted  in  the  cytoplasm.  Satellitosis  is  present  in  some 
areas  and  in  a  few  instances  there  are  severe  destructive 
cell  changes  and  active  neuronophagy.  The  medium  sized 
vessels  in  this  area  have  an  accumulation  of  lympho- 
cytes in  the  Virchow-Robin  space.  There  are  a  few 
small  hemorrhages  which  are  not  infiltrating  and  for  the 
main  part  are  confined  to  the  pei'ivascular  space  of  His. 


STUDIES  OF  SELECTED  CASES        163 

The  invading  cells  are  mainly  ameboid  glia,  though 
lymphocytes,  polyblasts,  plasma  cells  and  rarely  poly- 
morphonuclear leucocytes  are  observed.  In  the  medulla 
there  are  small  hemorrhages,  adventitial  lymph  space 
infiltration  of  some  of  the  vessels,  edema  and  scattered 
areas  of  cellular  accumulation.  The  nerve  cells  in  some 
instances  show  the  early  changes  of  acute  cloudy  swelling, 
but  nowhere  to  a  marked  degree.  Neuronophagy  is 
absent.  In  the  cord  there  is  marked  congestion  of  the 
gray  matter  and  to  a  less  extent  of  the  white.  Here  the 
motor  cells  show  evidence  of  moderate  acute  cloudy 
swelling. 

In  conclusion,  the  findings  are  chiefly  marked  vascular 
congestion  which  is  more  prominent  in  the  gray  matter  of 
both  brain  and  cord  than  in  the  white  matter,  but  most 
pronounced  in  the  central  ganglia.  There  are  small 
hemorrhages,  Virchow-Robin  space  infiltration  and  local- 
ized areas  of  edema  and  cellular  accumulation,  the  cells 
outside  of  the  vessel  spaces  being  niainly  ameboid  glia 
cells,  but  occasionally  lymphocytes,  polyblasts,  plasma 
cells,  and  very  rarely  polymorphonuclear  leucocytes  are 
seen.  The  changes  in  the  motor  cells  are  nowhere  marked 
and  consist  mainly  of  the  milder  grades  of  acute  cloudy 
sweUing. 


CHAPTER  XXII 

CASE    REPORT   VI 

Mr.  M.  P    Aged  forty.  Married.  Cabinetmaker. 

Admitted  to  the  hospital  June  1,  1919. 

Chief  Complaints.  Involuntary  movements  of  the 
head  and  legs,  difficulty  in  walking,  tremor  of  the  hands, 
constipation;  duration  five  months. 

Fmnily  History.  Parents  are  dead;  cause  unknown. 
Three  sisters  are  living  and  well;  two  brothers  dead,  one 
killed  in  Russia,  the  other  died  of  appendicitis.  No  famil- 
ial diseases.  No  nervous  or  mental  affections. 

Previous  History.  Scarlet  fever,  diphtheria  in  child- 
hood. Appendix  was  removed  three  years  ago.  He  has 
had  occasional  colds  and  sore  throat ;  no  severe  tonsillitis. 
No  rheumatism  or  chorea.  No  nervous  disorders.  Vene- 
real diseases  denied  by  name  and  symptom. 

Personal  History.  He  has  not  worked  at  his  occupa- 
tion of  cabinet  making  since  the  onset  of  this  illness,  owing 
to  his  involuntary  muscular  movements.  He  has  been 
married  seventeen  years;  his  wife  is  well,  except  for 
attacks  of  asthma.  He  has  had  six  children;  four  are  living 
and  well;  two  died,  one  from  scarlet  fever  and  the  other 
from  meningitis.  The  first  pregnancy  resulted  in  an 
early  miscarriage.  There  have  been  no  other  miscarriages. 
He  uses  no  alcoholic  drinks.  Until  the  onset  of  the  pres- 
ent illness  he  smoked  eight  or  ten  cigars  daily.  Takes  two 
cups  of  tea  daily,  coffee  only  occasionally.  Use  of  drugs  is 
denied. 

164 


STUDIES  OF  SELECTED  CASES        165 

Present  Illness:  Toward  the  end  of  December,  1918, 
the  patient  began  to  have  a  continual  ringing  in  the  ears 
associated  with  general  weakness.  A  week  later  he  sud- 


FiG.  33. — Ca!sk  VI.     Series  of  t'hutugnqui^  ^liuwin^  lik-  \  arious 
Phases  of  Movement  continually  Present.     No.  1. 

denly  felt  ill  and  went  to  bed.  A  physician  who  was  called 
made  a  diagnosis  of  influenza.  During  the  first  few  daj^s 
of  the  acute  illness  he  had  a  fever  accompanied  by  a 
cough  and  delirium.  This  was  followetl  by  progressive 


166  EPIDEMIC    ENCEPHALITIS 

drowsiness  which  merged  into  true  lethargy.  During 
this  period  the  patient  did  not  recognize  his  wife.  He 
was  fed  with  chfficulty,  had  extreme  difficulty  in  keeping 


Fig.  34.— Case  VI.     No.  2. 

his  eyes  open,  and  when  they  were  open  his  eyeballs 
would  roll  upwards.  There  was  no  strabismus  or  incoordi- 
nation noted.  The  wife  noted  a  flattening  of  the  left  side 
of  his  face,  a  very  peculiar  appearance  of  his  eyes  and 


STUDIES  OF  SELECTED  CASES        167 

an  entire  change  of  expression.  The  lethargic  state  lasted 
three  to  four  weeks.  After  this  there  was  a  period  of 
dullness  and  the  patient  was  perfectly  cognizant  of  his 


Fig.  35.— Case  VI.     No.  3. 

surroundings.  He  complained  of  occipital  pressure  and 
dizziness,  but  no  earache.  For  several  days  he  had  diffi- 
culty in  swallowing  and  ever^'-thing  he  ate  would  be 
regurgitated.  The  patient  has  only  a  vague  memory  of 


168 


EPIDEMIC    ENCEPHALITIS 


events  during  this  time.  He  gradually  emerged  from  the 
drowsy  state,  and  got  up.  For  the  next  two  or  three  days 
he  had  visual  hallucinations  which  frightened  him  and 
caused  him  to  break  out  in  cold  perspiration. 


Fig.  30. — Case  VI.     No.  4. 


After  recovery  he  was  quite  normal  for  two  v/eeks,  but 
rather  weak  and  had  a  continual  feeling  of  oppression  in 
the  occipital  region.  Then  he  began  to  have  involuntary 


STUDIES  OF  SELECTED  CASES        1G9 

irregular  movements  of  his  head.  These  were  mild  at  first 
but  got  progressively  worse.  After  a  while  the  movements 
would  occur  when  he  was  lying  down.  His  hands  got 
shaky  so  that  he  could  not  hold  a  newspaper.  Then  he 


began  to  have  involuntary  movements  of  his  right  leg 
which  were  synchronous  with  the  head  movements.  This, 
combined  with  a  feeling  of  weakness  in  the  knees,  made 
walking  very  difficult. 


170  EPIDEMIC    ENCEPHALITIS 

Ever  since  the  onset  of  his  illness  the  patient  has  had 
severe  constipation.  For  the  past  five  months  he  has  not 
had  a  stool  without  having  previously  taken  a  cathartic. 


Fig.  38. — Case  VI.     Composite  Photograph  with  Five  Exposures 
on  One  Plate  Showing  Movement  of  Head. 

Except  for  his  nervous  symptoms  he  has  felt  well  since 
his  acute  illness.  His  appetite  is  fair.  He  has  occasional 
indigestion  (a  burning  sensation  in  the  epigastrium  after 
meals),  no  nausea  or  vomiting;  no  distension  or  flatulence; 


STUDIES  OF  SELECTED  CASES 


171 


no  fever,  cough,  dyspnea 
or  headache.  There  has 
been  no  trouble  with 
vision.  The  ringing  in  the 
ears  still  occurs  fre- 
quently, but  he  has  had 
tinnitus  for  many  years. 
At  times  he  has  a  discharge 
from  one  of  his  ears.  He 
has  had  no  genito-urinar}' 
symptoms;  no  incon- 
tinence at  any  time.  Dur- 
ing his  illness  he  has  gained 
in  weight. 

PHYSICAL   EXAMINATION 

General  Appearance. 
A  well  developed,  well 
nourished,  middle-aged 
Russian  Hebrew.  He  does 
not  appear  ill.  There  is  no 
cyanosis,  edema  or  dys- 
pnea. As  the  patient  lies 
with  his  head  on  the  pillow 
he  is  quiet.  On  sitting  up, 
however,  there  are  curious 
involuntary  movements  of 
the  head  and  neck  which 
consist  of  a  jerking  back 
of  the  chin  at  frequent  in- 
tervals with  lateral  flexions 
of  the  head  to  one  side  or  the  other.  There  is  also  rota- 
tion of  the  head  to  either  side.  These  movements  are 


-Case    VI. 
Attitude. 


Standing 


172  EPIDEMIC    ENCEPHALITIS 

stereotyped,  and  follow  one  another  in  a  regular  se- 
quence. They  are  not  attended  with  any  pain.  There  are 
no  abnormal  movements  of  the  eyes.  There  is  some  diffi- 
culty in  speech  apparently  due  to  lack  of  coordination 
in  the  muscles  of  the  lips.  The  skin  is  warm  and  dry  with 
a  slight  acneform  eruption  over  the  back. 

Lymphatic  System:  There  is  no  glandular  enlarge- 
ment. 

Head:     The  scalp  is  clean. 

Eyes:  Conjunctivae  are  not  injected;  movements  are 
normal.  No  exophthalmos,  strabismus,  nystagmus  or 
ptosis.  The  pupils  are  equal,  regular  aiid  react  normally. 

Nose  and  ears  are  negative  to  external  examination. 

Mouth:  The  teeth  show  moderate  caries  and  pyorrhea 
with  many  gold  caps.  The  tongue  is  heavily  coated. 
The  pharynx  is  moderately  congested  about  the  fauces. 
The  tonsils  are  slightly  enlarged  and  congested. 

Neck  shows  no  abnormalities;  no  stiffness. 

Chest  is  symmetrical;  expansion  is  moderate  and  equal 
on  the  two  sides. 

Lungs  are  resonant  throughout.  Breath  sounds,  voice 
and  fremitus  are  normal.  There  are  no  rales. 

Heart  is  normal  in  size  and  position.  The  apex  beat 
is  not  felt.  There  are  no  abnormal  pulsations  or  thrills. 
The  sounds  are  not  well  heard  at  the  apex  or  base,  but 
appear  to  be  of  good  quality.  The  left  limit  of  dullness 
is  103^  centimeters  to  the  left  of  the  midline  in  the  fifth 
space.  The  pulses  are  equal  and  regular;  the  rate  and 
tension  are  normal.  Rate,  88.  Blood  pressure  145-90. 

Abdomen  is  soft.  No  abnormal  tympany.  No  masses 
or  tenderness.  Liver  and  spleen  are  not  felt. 

Genitals  are  normal. 

Extremities:  There  is  a  coarse  tremor  of  the  hands 
which  is  made  worse  by  voluntary  movements.  There  is 


STUDIES  OF  SELECTED  CASES        173 

no  cyanosis  or  edema.  There  is  occasional  involuntary 
movement  of  the  right  leg  which  consists  of  sudden 
slight  flexions  of  the  knee. 

Temperature  99.  Respirations  20.  Weight  11 G  pounds. 

LABORATORY    EXAMINATIONS 

Blood  Wasserynann:     Juno  2,  1919. 

Alcohol  antigen Nofj;ative 

Cholesterin  antigen Nejiativo 

Blood  Count:    June  2,  1919. 

Red  blood  cells .''),000,000 

Hemoglobin SO  per  cent. 

White  blood  cells 12,000 

Polymorphonuclear  leucocytes. .  67  per  cent. 

Lymphocj^tes 30  i)er  cent. 

Transitionals 2  per  cent. 

Basophiles 1  per  cent. 

Urine  Examination:    June  3,  1919. 

Specific  gravity 1.021 

Reaction Acid 

Precipitate Slight 

Albumin Negative 

Sugar Negative 

Microscopical  examination Negative 

Lumbar  Puncture:    June  4,  1919. 

Amount 9  c.c. 

Appearance Colorless,  clear 

Pressure Normal 

Cell  count 61  lymphocytes 

Globulin + 

Wassermann 2  c.c.      1  c.c.      .6  c.c.  .2  c.c. 

Alcohol  antigen Neg.       Neg.       Neg.      Neg. 

Cholesterin  antigen . . .  Neg.       Neg.       Neg.      Neg. 
Colloidal  gold Negative 

Eye  Examination:     June   13,   1919.     Retinal  arteries 
are  thin.  Otherwise  the  eyegrounds  are  negative.  There 


174  EPIDEMIC    ENCEPHALITIS 

is  possibly  a  slight  insufficiency  of  the  right  internal 
rectus.  Vision  is  normal. 

NEUROLOGICAL  examination:   JULY  8,    1919 

Voluntary  Motor  System.  Abnormal  Altitudes  and 
Dejormities.  As  the  patient  lies  in  bed  there  is  almost 
constant  movement  of  the  head.  When  it  is  quiet  the  face 
is  turned  to  the  right,  head  inclined  to  the  right  and 
backwards.  The  movement,  though  it  varies  in  severity 
and  amplitude,  follows  a  pretty  constant  formula.  Start- 
ing with  the  head  at  the  back  and  right,  it  moves  back- 
ward and  to  the  left,  then  forward  and  to  the  right 
again.  Throughout  the  movement  there  is  a  tendency  to 
maintain  the  tilting  of  the  head  to  the  right  and  back- 
wards. The  movement  is  never  in  the  reverse  direction. 
It  is  more  active  when  he  lies  on  the  right  side.  It  is 
also  increased  by  any  excitement,  for  instance,  during 
examination,  when  he  is  talking,  playing  checkers,  or  if 
he  reads  anything  especially  interesting  or  exciting. 

On  standing,  both  legs  are  flexed  at  the  knees,  the  left 
more  than  the  right,  the  alidomen  is  thrown  forward 
with  some  arching  of  the  back,  the  head  is  in  the  position 
described  before.  When  quiet  in  bed  there  is  no  particular 
position  in  which  the  arms  are  held;  but  when  he  attempts 
to  walk,  the  right  forearm  is  pronated  partially  flexed, 
and  the  hand  held  midway  between  the  open  and  closed 
position.  The  arm  is  internally  rotated  so  that  the  palm 
is  held  outward  and  backward. 

Gait.  On  walking  there  is  the  constant  movement  of 
his  head  already  described.  His  body  is  inclined  forward, 
both  legs  are  kept  slightly  flexed  at  the  knees.  The  steps 
are  of  about  normal  length  and  equal  on  the  two  sides; 
the  feet  are  raised  from  the  floor  a  little  more  than  is 
normal  and  the  toes  brought  down  to  the  floor  before  the 
heels. 


STUDIES  OF  SELECTED  CASES        175 

Coordination.  Equilibratory:  Standing  with  feet  to- 
gether, eyes  open,  there  is  ver}^  sHght  swaying.  The  sway- 
ing is  more  marked  when  his  eyes  arc  closetl,  but  he 
does  not  feel  dizzy. 

Non-equihbrator}^:  Finger-to-nose:  The  movements 
are  made  with  only  moderate  ataxia,  but  with  a  slight 
over-reaching  on  each  side.  Pointing  and  past  point- 
ing: There  is  an  over-reaching  of  about  two  inches  in 
movements  in  the  lateral  planes  with  each  liand.  The 
movements  in  the  vertical  plane  are  well  coordinated. 
Heel-to-knee:  The  heels  are  placed  three  to  six  inches 
above  the  knees  on  each  side.  As  a  rule  there  is  more 
over-reaching  with  the  left  leg.  The  movements  are 
carried  out  quickly  and  with  very  little  oscillation. 
Toe-to-object-above-recumbent-patient  test  is  accom- 
plished quite  well  on  each  side.  Dysmetria:  There  is 
none  with  the  eyes  open.  Adiadochokinesis  is  absent. 

Skilled  Acts.  There  is  no  dyspraxia.  Speech  is  usually 
slow  and  apparently  accomplished  with  some  effort. 
Most  of  the  difficulty  with  his  speech  seems  to  l)e  due  to 
the  constant  movement  of  his  head  rather  than  to  any 
inherent  disorder  of  the  speech  mechanism.  There  is  no 
aphasia. 
Reflexes: 

Deep  Right  Left 

Jaw 2  2 

Pectoral 2  2 

Biceps 2  2 

Triceps 2  2 

Radial ' 2  2 

Ulnar 2  2 

Wrist 2  2 

Suprapatellar 2  2 

Patellar 3  2 

Achilles 3  2 

Periosteal  uncrossed Absent  Alisent 

Periosteal  crossed Absent  Absent 


176  EPIDEMIC   ENCEPHALITIS 

Superficial  Right                     Left 

Ciliospinal Present  Present 

Supra-umbilical 2                     2 

Suprapubic 2                     2 

ITpper  lateral  abdominal 2                     2 

Lower  lateral  abdominal 2                     2 

Cremasteric 2                     2 

Plantar  flexion Present  Present 

Bahinski  and  modifications Absent  Absent 

On  testing  for  plantar  reflexes  there  is  a  slight  plantar  flexion 
of  the  toes,  but  a  very  marked  contraction  of  the  tensor  fascia 
femoris. 

Ah  normal  Involuntary  Movements.  There  is  a  slight  fine 
tremor  of  the  extended  fingers.  The  movement  of  the 
head  is  described  under  "Abnormal  Attitudes  and 
Deformities." 

Muscle  Strength.  The  patient  is  left-handed.  He 
writes  with  his  left  hand,  uses  the  saw  and  most  of  his 
cabinet-making  tools  with  the  left  hand,  but  uses  the 
plane  with  his  right  hand.  There  is  considerable  diminu- 
tion of  strength  in  the  muscles  of  all  extremities,  the 
grip  on  the  left  side  being  a  little  better  than  on  the  right. 
Otherwise  there  is  no  perceptible  difference  in  the 
strength  of  the  homologous  muscle  groups  on  the  two 
sides.  There  is  some  weakness  of  the  lower  portion  of 
the  face  on  the  right  side. 

Muscle  Status.  The  contour  is  normal,  consistency 
soft,  the  tone  is  normal. 

General  Sensory:  Touch:  Acuity, localization,  dis- 
crimination are  normal.  Pain  and  temperature  sense  are 
normal;  vibratory — tuning  fork  vibration  is  said  to  be 
felt  a  little  less  acutely  in  the  left  leg.  Pressure  over  the 
muscles  of  the  calf  and  thigh  is  felt  slightl}^  less  well  on 
the  left  side.  JXIuscle  tendon  sense  is  normal.  Stereognosis 
is  normal. 


STUDIES  OF  SELECTED  CASES        177 

Cranial  Nerves  and  Head.  Olfactory  Nerve  and 
Nose.  The  sense  of  smell  is  not  very  acute  on  either  side. 
The  odor  of  asafetida  is  detected  but  said  not  to  be 
unpleasant. 

Optic  and  Oculomotor  Apparatus.  Visual  acuity  is 
normal.  Perimetry,  by  the  finger  test  is  normal.  Eye- 
grounds  :  The  retinal  vessels  are  not  abnormally  tortuous 
or  congested.  There  are  no  hemorrhages.  The  disc  is  well 
outlined.  The  pupils  are  both  in  mid-dilatation  and  react 
actively  to  light  and  on  accommodation.  The  palpebral 
fissure  measures  10  millimeters  on  each  side.  There  is 
no  enophthalmos,  exophthalmos  or  ptosis.  There  is  no 
strabismus  or  other  ocular  deviation.  The  conjugated 
eye  movements  are  normal.  There  is  no  nystagmus. 

Acoustic  Nerve  and  Ear.  A  watch  is  heard  eighteen 
inches  from  each  ear.  Air  conduction  is  better  than  bone 
on  each  side. 

Trigeminus  Nerve  and  Mouth.  Taste  on  the  anterior 
two-thirds  of  the  tongue  on  each  side  is  normal.  There  is 
slight  weakness  in  the  lower  face  on  the  right  side,  but  no 
apparent  weakness  of  either  orbicularis  palpebrarum. 

Glossopharyngeus  and  Vagus  Nerves,  Pharynx  and 
Larynx.  The  uvula  hangs  in  the  median  position.  The 
palatal  and  pharyngeal  reflexes  are  present.  Swallowing 
is  normal. 

Spinal  Accessory  Nerve.  There  are  no  signs  of  paraly- 
sis on  either  side. 

Hypoglossus  Nerve  and  Tongue.  The  tongue  is  pro- 
truded shghtly  to  the  right  of  the  median  Hne,  but  the 
movements  seem  to  be  equal  in  all  directions.  There  is  a 
slight  ataxia  noted  in  the  rapid  movements  of  the  tongue. 
It  can  be  moved  back  and  forth  and  laterally  quite 
quickly,  but  cannot  be  moved  rapidly  in  the  up  and  down 
direction. 


178  EPIDEMIC    ENCEPHALITIS 

Mental  Status,  At  present  the  patient  is  perfectly 
clear  mentally.  He  complains  of  a  lack  of  memory  for 
recent  events,  but  his  memory  for  past  events  is  good. 
He  has  some  difficulty  in  thinking  of  words  that  he  wishes 
to  use  but  seems  quick  and  alert  and  able  to  think  promp- 
tly. Some  months  ago  he  had  visual  hallucinations,  but 
these  have  entirely  disappeared.  He  states  that  at  times 
strange  thoughts  come  into  his  mind  without  obvious 
association  or  reason.  He  realizes  that  this  is  abnormal 
and  it  worries  him  a  little,  but  he  believes  that  it  will 
pass  away  and  he  does  not  wish  to  discuss  it.  He  is  con- 
fident that  he  will  entirel}^  recover  and  is  not  in  any  way 
worried  about  his  condition. 

The  patient  remained  in  the  hospital  six  weeks,  his 
condition  gradually  improving.  His  gait  became  steadier 
and  the  tremor  of  his  hands  practically  disappeared. 
The  movements  of  his  head,  although  much  diminished, 
still  persisted  and  were  exaggerated  by  emotional  influ- 
ences. His  speech  difficulty  which  apparentl}^  depended 
largely  upon  the  constant  movements  of  the  head,  was 
much  less. 

While  in  the  hospital  the  treatment  consisted  of  rest 
and  anti-constipation  diet  and  regime. 

July  25,  1919.  A  note  from  the  patient  states  that 
there  has  been  but  little  improvement  since  leaving  the 
hospital,  the  movement  of  the  head  still  being  almost 
continuous. 


CHAPTER  XXIII 


CASE    REPORT  VII 


Mr.  N.  H.  Aged  thirty-two.  Married.  Chemist. 

Admitted  to  the  hospital  June  12,  1919. 

Chief  Com'plaint.  Difficulty  in  walking  and  speech, 
duration  five  months. 

Family  History.  Mother  is  living  and  well;  father  is 
dead,  cause  unknown.  Two  brothers  and  three  sisters 
are  living  and  well. 

Personal  History.  He  is  a  chemist.  Has  been  married 
three  years.  His  wife  is  living  and  well.  He  has  one  healthy 
child.  His  wife  had  one  miscarriage  last  winter,  at  four 
months.  He  uses  no  alcohol,  tobacco  or  drugs.  Takes 
tea  occasionally;  no  coffee. 

Past  History.  Has  had  no  serious  illnesses,  never 
having  been  sick  in  bed  before.  Has  had  severe  acne  since 
the  age  of  15,  with  numerous  boils  and  carbuncles.  He 
had  pains  in  the  legs  for  six  months  prior  to  present  ill- 
ness. Gonorrhea  and  sj'philis  denied.  Soft  chancre  six 
years  ago. 

Present  Illness.  The  onset  of  the  present  illness  was 
five  months  ago  following  an  attack  of  influenza.  He  was 
sick  with  a  mild  fever  and  general  pains  for  three  weeks 
in  the  Brooklyn  Jewish  Hospital.  The  following  report 
was  obtained  from  this  hospital:  The  patient  was  ad- 
mitted on  January  19,  1919,  complaining  of  fever, 
cough  and  substernal  pain,  of  six  days'  duration.  The 
family,  past  and  personal  history  were  good  except  that 
he  had  had  influenza  three  months  prior  to  admission. 

179 


180  EPIDEMIC    ENCEPHALITIS 

During  his  stay  in  the  hospital  he  ran  a  temperature 
ranging  from  104  to  105°.  He  had  typical  signs  of  pneu- 
monia of  the  right  lower  lobe.  The  pulse  was  very  rapid. 
He  was  markedly  dyspneic  with  signs  of  slight  pulmo- 
nary edema.  His  abdomen  was  markedly  distended  and 
he  suffered  from  bladder  retention  and  had  to  be  cathe- 
terized  repeatedly.  On  the  fifth  day  the  patient  had  a 
crisis  which  was  followed  by  an  apparently  normal  con- 
valescence. For  the  next  two  days  he  appeared  asthenic, 
but  not  more  so  than  is  seen  in  convalescence  from  severe 
pneumonia.  On  the  third  day  of  convalescence  he  could 
be  roused  only  with  difficulty  and  slept  most  of  the  time. 
When  asking  for  something  it  was  noticed  that  he  could 
speak  only  in  a  whisper.  Following  this  he  became  some- 
what restless.  His  thinking  was  very  slow  and  he  voided 
involuntarily.  He  was  conscious  of  this  fact  and  worried 
over  it.  The  difficulty  in  speech  became  worse,  so  that 
he  could  talk  only  with  exertion.  He  pronounced  his 
words  indistinctly.  The  neurological  findings  at  this  time 
were  as  follows:  Speech  slow  and  scanning;  slight  weak- 
ness of  the  left  side  of  the  face;  both  knee  jerks  very 
active;  slight  ankle  clonus;  no  Babinski.  Abdominal 
reflexes  were  normal.  There  was  marked  ataxia  of  the 
lower  extremities.  There  was  some  difficulty  in  swallow- 
ing but  the  throat  examination  showed  no  paralysis  of 
the  palate  or  pharynx.  The  mentality  was  normal.  The 
pupils  reacted  actively  to  light  and  on  accommodation. 
The  ocular  movements  were  normal,  there  was  no  nystag- 
mus and  both  fundi  were  normal. 

As  time  went  on  his  appetite  improved.  Urination  and 
defecation  became  normal.  He  was  mentally  perfectly 
clear  but  he  still  had  marked  difficulty  in  speaking.  His 
face  remained  expressionless. 

There  was  a  moderate  leucocytosis  at  the  time  of  his 


STUDIES  OF  SELECTED  CASES        181 

pneumonia.  His  urine  showed  a  trace  of  albumin.  Blood 
pressure  was  normal;  blood  culture  sterile.  Sputum 
examination  showed  non-hemolitic  streptococci  and 
staphylococcus  pyogenes  aureus. 

The  patient  was  discharged  February  21,  1919,  the 
pulmonary  condition  having  entirely  cleared  up.  He 
was  still  markedly  weak,  his  face  was  expressionless, 
speech  slow  and  difficult,  and  gait  ataxic. 

The  weakness  and  difficulty  in  walking  that  were 
noted  on  his  leaving  the  Brooklyn  Jewish  Hospital 
have  persisted  up  to  the  present  when  he  is  unable  to 
walk  without  a  cane.  If  he  attempts  to  walk  unaided 
he  sways  and  usually  falls.  There  is  no  tendency  to  fall  in 
any  particular  direction.  Since  the  onset  he  has  had 
difficulty  in  talking;  he  knows  what  he  wants  to  say, 
but  has  a  hard  time  forming  the  words.  At  times  he  has 
severe  frontal  headaches;  these  come  on  usually  at  night 
and  last  only  a  few  minutes.  Occasionally  he  vomits 
small  quantities.  This  often  occm's  while  going  to  bed. 
It  is  not  associated  with  headaches  or  accompanied  by 
nausea.  His  appetite  is  poor.  He  sleeps  poorly.  The  bowels 
are  regular.  The  general  health  is  fairly  good;  he  has 
gained  some  weight  recently.  He  has  not  been  able  to 
work,  owing  to  the  difficulty  in  walking  and  in  speech. 

PHYSICAL    EXAMINATION,    JUNE    12,    1919. 

General  Appearance.  A  healthy-looking,  well-nour- 
ished Hebrew  of  32.  Good  color.  No  dyspnea  or  cyanosis. 
He  lies  in  bed  apparently  comfortable,  seeming  some- 
what apathetic.  His  face  has  a  singular  lack  of  expression. 
His  speech  has  a  deliberate,  emphatic  quality,  is  some- 
what jerky  and  has  a  scanning  chairacter;  it  is  low-pitched 
and  monotonous.  He  has  a  curious  bodily  configuration, 


182  EPIDEMIC    ENCEPHALITIS 

the  legs  appearing  too  short  for  the  trunk.  The  shortening 
is  in  the  bones  of  the  legs  which  are  very  slender  compared 
with  the  rounded  fat  thighs.  Fullness  of  the  thighs  and 
the  knock-knees  give  a  feminine  character  to  the  appear- 
ance. The  genitals  are  under-developed;  crines  pubis 
flattened  above,  absence  of  pectoral  hair.  The  hands  and 
feet  are  small  and  delicate.  There  is  slight  nodding  of  the 
head.  The  skin  is  warm  and  oily.  Over  most  of  the  body, 
but  most  noticeable  over  the  back,  chest  and  thighs, 
there  is  an  extensive  indurated  acneform  eruption 
consisting  of  comedones,  papules  and  large  pustules. 
There  are  numerous  scars  of  all  sizes  resulting  from  inci- 
sions of  previous  furuncles. 

Lymphatic  System:     No   glandular  enlargement. 

Head:  Scalp:  The  hair  is  thick  and  oily  with  a  low 
hair-line. 

Face:  Skin  oily;  several  scars  and  fresh  papules. 
There  is  an  absence  of  facial  expression  and  no  spon- 
taneous smiling.  There  is  very  little  movement  of  the 
left  angle  of  the  mouth  in  talking. 

Nose:  Wide  anteiior  nares.  No  obstruction  or 
discharge. 

Ears:     Negative. 

Eyes:  Conjunctivae  and  sclerae  clear.  Movements  nor- 
mal. Pupils  small  and  regular,  the  right  slightly  larger 
than  the  left.  Both  react  promptly  to  light  and  on 
accommodation. 

Mouth:  Lips  are  of  good  color.  Teeth  show  moderate 
pyorrhea;  several  gold  crowns.  Tongue  is  clean.  Pharynx 
is  somewhat  reddened.  Tonsils  not  enlarged. 

Neck:     No  thyroid  enlargement  or  other  abnormality. 

Chest:  Symmetrical  but  poorly  developed.  Expansion 
is  limited  on  both  sides.  The  lungs  are  resonant  through- 
out. Breath  sounds  are  diminished  owing  to  inability 


STUDIES  OF  SELECTED  CASES        183 

to  breathe  properly.  Fremitus  and  voice  sounds  are 
normal.  There  are  no  rales. 

Heart  is  normal  in  size  and  position.  Apex  impulse 
is  not  felt.  No  abnormal  pulsations  or  thrills.  The  rate 
is  rapid  but  regular;  tension  normal.  The  sounds  at  the 
apex  are  of  good  quality,  at  the  base  the  aortic  second 
sound  is  slightly  greater  than  the  pulmonary  second. 
There  are  no  murmurs.  Pulses  are  equal,  regular,  rate 
92.  Blood  pressure  148-90. 

Abdomen  is  full  and  rounded,  soft,  moderately  tympani- 
tic; no  masses  or  tenderness.  Liver  and  spleen  not  felt. 

Genitalia  are  small. 

Extremities:  No  cyanosis  or  edema.  All  the  deep 
reflexes  are  hyperactive.  There  is  a  coarse  tremor  of  the 
hands. 

LABORATORY    EXAMINATIONS 

Lumbar  Puncture,  June  13,  1919. 

18-20  c.c.  of  spinal  fluid  obtained  under  normal  pressure  were 
clear  and  colorless.  The  fluid  then  became  bloody.  Toward  the 
end  of  the  aspiration  the  amount  of  blood  became  progressively 
less. 

Cells  (Fluid  bloody) 

Globulin  not  determined  (Fluid  bloody) 

Wassermann 2  c.c.      1  c.c.      .2  c.c.     .6  c.c. 

Alcohol  antigen Neg.       Neg.       Neg.       Neg. 

Cholesterin  antigen .  .  .  Neg.       Neg.       Neg.       Neg. 
Culture Sterile 

Blood  Count:  June  13,  1919. 

Red  blood  cells .'i,000,000 

Hemoglobin 85  per  cent. 

White  blood  cells 29,700 

Polymorphonuclear  leucocytes. .  59  per  cent. 

Lymphocytes 40  per  cent. 

Eosinophiles 1  per  cent. 


184  EPIDEMIC    ENCEPHALITIS 

Urine  Examination:  June  14,  1919. 

Specific  gravity 1.020 

Reaction Acid 

Color Amber 

Precipitate Slight 

Albumin A  very  faint  trace 

Glucose None 

Microscopical  examination A  few  amorphous  urates 

Blood  Count:  June  20,  1919. 

White  blood  cells 20,000 

Polymorphonuclear  leucocytes 63  per  cent. 

Lymphocytes 37  per  cent. 

Eye  Examination:  June  13,  1919.     (Dr.  Schoenberg). 

The  left  cornea  is  less  sensitive  than  the  right.  There  is 
no  ptosis  or  convergent  insufficiency.  Both  fundi  are 
normal.  Vision  is  normal. 

NEUROLOGICAL    EXAMINATION  I  JUNE  27,  1919 

Voluntary  Motor  System.  Abnormal  Attitudes  and 
Deformities.     Previously  described. 

Gait.  He  is  unable  to  walk  unaided.  When  hands  are 
supported  he  walks  with  feet  far  apart.  The  knees  are 
brought  up  high,  the  feet  planted  down  flatly. 

Coordination.  Equilihratory:  Standing  with  the  feet 
together,  eyes  open,  there  is  marked  swaying,  with  eyes 
closed  the  swaying  is  somewhat  increased.  He  is  unable 
to  stand  on  either  foot  unaided.  Non-equilibratory: 
Finger-to-nose  test:  The  movement  on  each  side  is 
attended  by  slight  ataxia.  Heel-to-knee  test  is  accom- 
plished with  a  good  deal  of  wobbhng  of  the  foot,  the  heel 
at  last  being  placed  above  the  knee  on  each  side.  Dys- 
metria  is  not  present.  Adiadochokinesis :  The  movements 
of  pronation  and  supination  are  rather  slow  and  delib- 
erate, but  not  irregular. 


STUDIES  OF  SELECTED  CASES        185 

Skilled  Acts.  There  is  no  dyspraxia.  Speech  is  slow, 
difficult,  scanning,  low-pitched,  with  very  little  inflec- 
tion. The  hand-writing  is  poor,  due  to  the  marked 
tremor  of  the  hands. 

Reflexes: 

Deep  Right  Left 

Jaw 2  2 

Pectoral 2  2 

Biceps 3  3 

Triceps 3  3 

Radial 3  3 

Ulnar..  .■ 3  3 

Wrist 3  3 

Scapular 3  3 

Patellar 4  4 

Achilles 4  4 

Periosteal  uncrossed Present  Present 

Periosteal  crossed Present  Present 

Superficial 

Ciliospinal Present         Present 

Abdominal All     present,     but     are 

easily  fatigued  so  that 
they  disappear  after 
being  elicited  a  few 
times,  the  disappear- 
ance occurring  at  the 
same  time  on  each  side. 

Cremasteric 2  1 

Plantar  flexion Present  Present 

Babinski Absent  Absent 

Abnormal  Involuntary  Movements.  There  is  a  moderate 
tremor  of  both  hands  made  slightly  worse  by  voluntary 
eft'ort. 

Muscle  Strength.  The  patient  complains  of  general 
weakness.  This  is  not  particularly  evident  when  muscle 
strength  is  tested.  He  says  that  his  neck  becomes  tired 
when  he  holds  his  head  up,  his  back  tires  when  sitting 


186  EPIDEMIC    ENCEPHALITIS 

up,  his  limbs  feel  weak  when  he  attempts  to  stand.  There 
is  no  apparent  difference  in  the  weakness  on  the  two 
sides. 

Muscle  Status.  The  muscles  everywhere  seem  well 
developed.  Consistency  and  tone  are  normal. 

Abnormal  Associated  Movements.     None  present. 

Nerve  Status.     Nothing  noted. 

General  Sensory.  Touch:  Acuity,  localization  and 
discrimination  normal.  Pain  normal.  Temperature  (cool 
and  warm)  normal.  Vibratory  normal.  Pressure,  muscle 
tendon  sense  and  stereognosis  normal. 

Cranial  Nerves  and  Head.  Olfactory  Nerve  and 
Nose.     Smell  is  normal  on  each  side. 

Optic  and  Oculomotor  Apparatus.  Visual  acuity  is 
normal.  Perimetry,  roughly  tested,  normal.  Eyegrounds 
normal.  Pupils  in  mid-dilatation,  regular  and  equal. 
Reaction  to  light  and  on  accommodation  normal.  Palpe- 
bral fissures  are  equal,  each  measuring  10  millimeters. 
There  is  no  exophthalmos  or  enophthalmos;  no  ptosis. 
Strabismus  is  absent.  Conjugated  eye  movements  are 
normal;  nystagmus  is  absent. 

Acoustic  Nerve  and  Ear.  A  watch  is  heard  at  twenty 
inches  from  each  ear.  Air  conduction  is  greater  than  bone 
on  each  side. 

Trigeminus  Nerve  and  Mouth.  The  patient  is  unable 
to  move  his  jaw  forward  or  sideways;  he  says  that  he  has 
never  tried  to  do  this.  The  conjunctival  reflex  is  present 
on  each  side  the  left  cornea  being  slightly  less  sensitive 
than  the  right. 

Facial  Nerve  and  Face.  The  right  side  is  normal.  On 
the  left  side  there  is  a  slight  weakness  of  the  lower  facial 
muscles  evidenced  in  attempting  to  show  his  teeth. 
Taste  on  the  anterior  two-thirds  of  the  tongue  on  both 
sides  is  normal. 


STUDIES  OF  SELECTED  CASES        187 

Glossopharyngeus  and  Vagus  Nerves,  Pharynx  and 
Larynx.  The  uvula  is  in  the  midline.  Palatal  and  phar- 
yngeal reflexes  are  normal.  There  is  no  difficulty  in 
swallowing. 

Spinal  Accessory  Nerve  is  normal. 

Hypoglossus  Nerve  and  Tongue.  The  tongue  is  pro- 
truded in  the  midline.  He  is  unable  to  move  the  tongue 
quickly  in  any  direction.  He  cannot  fold  the  tongue  or 
produce  a  rapid  up  and  down  or  lateral  oscillation  of  the 
tip.  The  trophic  status  of  the  tongue  is  normal. 

During  the  patient's  nine  weeks'  stay  in  the  hospital 
he  gradually  improved  with  rest  and  massage.  His 
walking  became  steadier  and  less  spastic  and  all  of  his 
movements  better  coordinated.  His  writing,  which  has 
been  nearly  bej'^ond  recognition  was  markedly  improved. 
The  speech  remained  difficult  and  little  changed. 

November  30th,  1919.  A  note  from  the  patient  states 
that  his  condition  has  remained  almost  stationary  since 
leaving  the  hospital. 


CHAPTER  XXIV 


CASE    REPORT  VIII 


Mr.  S.  K.  Aged  twenty-eight.  Occupation,  Locomotive 
fireman. 

Admitted  to  hospital  December  1,  1919. 

Chief  Complaint.  Clumsiness  and  stiffness  in  right 
shoulder,  arm  and  hand,  and  to  a  less  degree  in  the  right 
leg.  Duration  ten  months. 

Family  History.  Mother  died  of  pneumonia  aged  fifty- 
eight;  father  died  of  pneumonia  at  the  age  of  sixty- 
seven.  Two  brothers  and  three  sisters  are  well.  No 
history  of  nervous  disorders  in  the  family.  No  heart  or 
kidney  trouble. 

Personal  History.  The  patient  is  single.  His  work  is 
strenuous,  occupying  eight  hours  a  day.  He  smokes  ten 
cigarettes  and  drinks  four  glasses  of  beer  and  one  of 
whiskey  daily.  His  best  weight  was  145  pounds  one  year 
ago.  He  now  weighs  133. 

Previous  History.  No  operations.  Measles  when 
twenty-one  or  twenty-two.  Jaundice  when  seventeen 
which  lasted  one  week. 

Head:  No  headache  prior  to  an  attack  of  influenza 
ten  months  ago. 

Eyes,  ears  and  speech  were  negative  prior  to  this  illness. 

Nose:     Negative. 

Teeth  bad;  had  some  dentistry. 

Respiratory:  No  grip,  bronchitis  or  pneumonia.  No 
night  sweats. 

188 


STUDIES  OF  SELECTED  CASES        189 

Gastrointestinal:  Had  bloody  diarrhea  when  a  child. 
Duration  three  days. 

Cardiovascular:    Negative. 

Genito-Urinary :  Urination  four  to  five  times  a  day, 
once  or  twice  at  night.  No  dysuria  or  incontinence. 
Gonorrhea  and  lues  denied.  Since  the  attack  of  influenza 
he  has  been  impotent. 

Neurological:  Negative  up  to  the  time  of  this  illness. 
He  is  not  nervous.  His  memory  is  good. 

Present  Illness.  About  ten  months  ago  he  had  influ- 
enza and  was  in  bed  ten  days  with  prostration,  fever, 
aches  all  over  body,  cough  and  sputum  which  was  never 
blood-tinged.  Was  not  treated  by  a  physician.  He  slept 
a  great  deal  during  his  illness  and  was  drowsy  and  dull. 
He  did  not  work  for  the  following  three  weeks  and  during 
the  first  week  after  getting  up  he  complained  of  frontal 
headaches  nearly  every  morning.  These  headaches  were 
dull  in  character.  At  this  time  he  had  trouble  with  his 
vision.  Near  objects  were  blurred  so  that  he  was  unable  to 
read  anything,  while  distant  objects  were  seen  as  clearly 
as  ever.  There  was  no  double  vision.  This  condition  con- 
tinued for  two  to  three  weeks  and  gradually  cleared  up. 
He  was  first  able  to  read  large  print  and  a  little  later 
small  type  could  be  seen  as  plainly  as  before  he  became 
ill.  His  hearing  also  became  poor.  It  was  diminished  to 
about  the  same  extent  in  each  ear.  Soft  sounds  were 
not  heard  at  all  and  louder  noises  seemed  distant.  His 
speech  became  slower  and  slurring.  He  runs  words  to- 
gether and  at  times  has  difficulty  in  spealdng.  The  head- 
aches, visual  disorder  and  poor  hearing  lasted  two  or 
three  weeks,  the  speech  change  has  remained.  His  hear- 
ing is  good  now  except  that  when  he  is  over-fatigued  it  is 
somewhat  diminished.  He  lost  10  to  15  pounds  in  the 
past  year.  While  his  right  hand  seems  about  as  strong  as 


190  EPIDEMIC    ENCEPHALITIS 

the  left  he  has  difficulty  in  using  it  because  of  an  ina- 
bility to  perform  any  movements  quickly  and  without 
conscious  effort.  He  first  noticed  that  he  was  very  clumsy 
in  the  use  of  this  hand.  He  could  not  get  it  in  his  pocket 
as  easily  as  formerly.  Writing  was  so  laborious  it  was 
impossible  for  practical  purposes.  The  same  condition 
is  present  to  a  less  degree  in  the  right  leg.  This  is  noticed 
in  walking,  climbing  stairs  and  in  getting  in  and  out  of 
bed.  There  is  no  pain  except  at  times,  usually  at  night, 
when  the  fingers  become  numb  and  slightly  painful. 
The  left  extremities  are  normal.  Since  his  illness  ten 
months  ago  he  has  been  slightly  more  sleepy,  not  nearly 
so  lively  and  active,  and  is  generally  weaker.  He  looks 
straight  ahead  or  watches  his  feet  in  walking. 

PHYSICAL    EXAMINATION 

General  Appearance:  A  young  adult  man  fairly  well 
nourished,  lying  quietly  in  bed  without  signs  of  acute  or 
chronic  illness.  There  is  a  lack  of  expression  in  his  face 
and  a  slight  flattening  of  the  right  naso-labial  groove. 

Skin  is  dry,  cool  and  soft. 

Lymph  Nodes:     Not  pathologically  enlarged. 

Head:    Long,  narrow  type;  symmetrical. 

Eyes:  Pupillary  reactions  normal.  Conjunctivae  clear; 
no  petechiae. 

Ears  and  Nose:  Negative  to  external  examination. 
No  marked  defect  in  hearing. 

Mouth:  The  tongue  is  clean  and  moist,  it  deviates  to 
the  right.  There  is  a  tremor  of  the  tongue. 

Teeth:     Carious  lower  left  molar  root. 

Face:  The  right  face  is  slightly  flattened.  No  evident 
paralysis. 


STUDIES  OF  SELECTED  CASES        191 

Throat:     The  uvula  is  in  the  midline.  Slight  conges- 
tion. No  obvious  tonsillar  disease. 
Neck:     No  stiffness;  no  paralysis. 


Fig.  40.— Case  VIII.     Weakness  of  Right  Half  of  Tongue. 

Chest:  Fairly  well  developed.  Expansion  equal  and 
good. 

Lungs:  Clear  and  resonant  throughout. 

Heart:  Not    enlarged    to    percussion.    No    point    of 


192  EPIDEMIC   ENCEPHALITIS 


Fig.  41. — Case  VIII.     Mask-like  Face  and  Characteristic  Posi- 
tion of  Arm. 


STUDIES  OF  SELECTED  CASES        193 

maximum  pulsation  at  apex.  Sounds  are  regular  and  of 
fair  quality.  No  murmurs.  Blood  pressure  125-85.  Pulse 
is  regular,  average  rate,  moderate  volume  and  tension. 
Vessel  wall  not  felt. 

Abdomen:  Considerable  muscular  spasm.  No  masses 
or  viscera  felt.  Superficial  abdominal  reflexes  present. 

NEUROLOGICAL   EXAMINATION:    DECEMBER   3,    1919 

Voluntary  Motor  System.  Abnormal  Attitudes 
and  Deformities.  On  standing  there  is  evidenced  little 
that  is  abnormal  except  that  the  right  hand  and  arm 
are  held  rigidly  in  one  position.  The  forearm  is  flexed, 
the  hand  extended  at  the  wrist,  the  fingers  partially 
flexed  at  the  metacarpo-phalangeal  joint.  There  is  a 
distinct,  wax-like  immobility  of  the  features  and  a  flat- 
tening of  the  naso-labial  furrows.  The  head  is  inclined 
slightly  forward  and  the  neck  held  stiffly.  On  looking 
to  the  side,  turning  of  the  head  is  avoided,  the  body  as  a 
whole  being  moved  instead. 

Gait.  There  is  little  objective  alteration,  though  the 
patient  complains  of  a  stiffness  and  a  dragging  of  the 
right  leg.  A  slight  clumsiness  is  noted  in  the  swinging 
of  this  leg  as  he  quickly  turns  to  the  right.  He  is  able 
to  walk  on  his  toes  or  heels,  sideways  or  backwards, 
without  cHfficulty. 

Coordination,  There  is  no  swaying  on  standing  with 
feet  together  or  on  the  left  foot  alone  with  the  eyes 
closed.  There  is  some  unsteadiness,  however,  on  stand- 
ing on  the  right  foot.  The  finger-to-nose,  pointing  and 
past  pointing  and  heel-to-knee  movements  are  carried 
out  with  normal  precision,  though  the  movements  of 
the  right  hand  are  deliberate. 

Skilled  A  ds.  There  is  no  dyspraxia  or  aphasia.  Speech 
is  usually  slow.  There  is  a  definite  hesitation  as  he  starts 

13 


194  EPIDEMIC    ENCEPHALITIS 

to  speak  and  then  the  words  come  rather  slowly,  but 
occasionally  are  shot  out  explosively,  "all  in  a  bunch," 
as  he  expresses  it.  The  voice  is  soft,  dull  and  monotonous. 
Reflexes: 

Deep  Right  Left 

Jaw 2  2 

Pectoral 2  2 

Biceps 3  2 

Triceps 3  2 

Radial 3  2 

Ulnar 3  2- 

Patellar 3  2 

Achilles 2  2 

Superficial 

Ciliospinal Presen  t  Present 

Supra-umbilical 2  2 

Suprapubic 2  2 

Upper  lateral  abdominal 2  2 

Lower  lateral  abdominal 2  2 

Plantar  flexion Present  Present 

Babinski  and  modifications Absent  Alisent 

Abnormal  Involu7itary  Movements.  There  are  no  ab- 
normal involuntary  movements  except  when  he  endeav- 
ors to  perform  active  movements  with  the  right  hand, 
when  there  is  a  motlerate,  coarse,  and  slow  interphal- 
angeal  trembling. 

Muscle  Sirerigth.  The  strength  of  opposed  and  un- 
opposed symmetrical  movements  seems  about  equal  on 
the  two  sides.  The  grip  in  the  right  hand  is  possibly  a 
little  less  than  in  the  left.  All  movements  of  the  right 
forearm,  hand  and  fingers  are  carried  out  slowly.  There 
is  extreme  retardation  and  absence  of  some  of  the  finer 
finger  movements.  Complete  extension  of  the  fingers  is 
difficult.  Hyper-extension  and  full  abduction  are  im- 
possible. It  is  very  hard  for  him  to  pick  up  a  coin  from  a 
table  unless  he  gets  his  finger-nails  under  it.  Writing  is 
so  slow  that  it  is  impossible  for  practical  purposes,  and 


STUDIES  OF  SELECTED  CASES        195 

he  has  learned  to  write  with  the  left  hand.  On  attempting 
to  carry  out  opposed  movements  alternately,  as  supina- 
tion and  pronation  of  the  forearm  on  the  right  side  there 
is  decided  sluggishness  and  incompleteness  of  movement. 
Retardation  is  present  in  the  right  leg,  but  to  a  much  less 
degree.  He  notes  an  inability  to  move  this  leg  as  freely 
as  the  other  in  getting  in  and  out  of  bed.  He  cannot 
extend  and  flex  the  leg  at  the  knee  as  fully  and  rapidly 
as  on  the  left.  In  the  right  arm  there  is  considerable 
resistance  to  passive  motion,  slow  movements,  encounter- 
ing the  same  resistance  as  more  rapid  ones. 

Muscle  Status.  Volume  and  contour  are  normal. 
There  is  slight  hypertonia  of  the  muscles  of  the  right 
arm  and  a  tendency  to  flexibilitas  cerea. 

Abnormal  Associated  Movements.     Not  tested. 

Nerve  Status.     No  observation. 

General  Sensory.  Touch,  pain,  temperature,  vibra- 
tory, pressure,  muscle  tendon  sense  and  stereognostic 
perception  are  normal. 

Cranial  Nerves  and  Head.  Olfactory  Nerve  and 
Nose.     Smell  is  normal  in  each  nostril. 

Optic  and  Oculomotor  Apparatus.  Visual  acuity  is 
normal  in  each  eye.  There  is  no  perimetric  contraction 
of  either  field.  The  eyegrounds  are  normal.  The  pupils 
are  equal  each  measuring  3  millimeters.  They  are  cen- 
trally placed,  regular,  and  react  actively  to  light  and 
on  accommodation.  The  palpebral  fissure  appears  very 
slightly  larger  on  the  right  side.  There  is  no  ptosis,  stra- 
bismus or  ocular  deviation.  Conjugated  eye  movements 
are  normal  except  for  a  slight  limitation  of  convergence. 
Nystagmus  is  absent. 

Acoustic  Nerve  and  Ear.  A  watch  is  heard  thirty 
inches  from  each  ear.  The  Rinne  test  is  normal. 


19G  EPIDEMIC    ENCEPHALITIS 

Trigeminus  Nerve  and  Mouth.  Movements  of  the 
lower  jaw  are  equal.  The  corneal  reflex  is  present  and 
there  is  no  alteration  in  sensibility  in  the  areas  suppUed 
by  this  nerve. 

Facial  Nerve  and  Face.  The  sense  of  taste  is  somewhat 
delayed  on  the  anterior  two-thirds  of  the  tongue  on  each 
side,  but  shows  no  asymmetrical  differences.  There  is  a 
slight  flattening  of  the  lower  portion  of  the  face  on  the 
right  side  and  a  lagging  of  the  right  corner  of  the  mouth 
on  showing  the  teeth. 

Glossopharyngeus  and  Vagus  Nerves,  Pharynx  and 
Larynx.  The  uvula  is  in  the  midline;  the  palatal  re- 
flexes and  the  pharyngeal  reflex  are  active.  Swallowing, 
respiratory  and  cardiac  action  are  normal. 

Hypoglossus  Nerve  and  Tongue.  On  protrusion  the 
tongue  deviates  to  the  right  and  its  movement  to  the 
left  is  limited.  There  are  no  visible  trophic  changes. 

LABORATORY    EXAMINATIONS   AND    CLINICAL   NOTES: 

Eye  Examination:  December  2,  1919.  (Dr.  Schoen- 
berg) . 

Abduction  is  good  in  both  eyes  and  adduction  poor. 
He  focuses  with  the  right  eye,  the  left  eye  rolling  out 
on  convergence.  Optic  nerves  normal.  There  is  a  pale 
ring  surrounding  the  optic  nerve  in  both  eyes  suggestive 
of  slight  process  in  choroid  surrounding  the  nerve. 
These  rings  are  found  in  myopias  in  young  people  and 
consist  of  mild  degeneration  of  choroid  due  to  unknown 
cause,  probably  toxic.  This  patient  is  not  myopic  and  the 
similarity  to  myopic  changes  is  only  mentioned  as  a 
point  of  comparison.  Probablj^  toxic  in  this  case.  Will 
not  interfere  with  vision. 


STUDIES  OF  SELECTED  CASES        197 

Lumhar  Puncture:     December  2,  1919 

Pressure Not  increased 

Amount 20  c.c. 

Appearance Blood-tinged 

Cells Numerous  red  cells. 

Count  not  made 

Globulin Negative 

Culture No  growth 

Wassermarm : 

Alcohol  antigen Negative 

Cholesterin  antigen Negative 

December  5,  1919.  Right  pupil  larger  than  left  to-day. 

Blood  Count:     December  8,  1919. 

Red  blood  cells 5,060,000 

Hemoglobin 65  per  cent. 

White  blood  cells 12,000 

Polymorphonuclear  leucocytes. .  78  per  cent. 

Lymphocytes 22  per  cent. 

Urine  Examination:     December  2,  1919. 

Specific  gravity 1.026 

Reaction Acid 

Color Amber 

Precipitate None 

Albumin None 

Glucose None 

Microscopical  examination Negative 

Temperature  while  in  the  hospital  ranged  from  normal 
to  99.6°. 

Pulse  Rate:     60—84. 

SUMMARY 

The  onset  was  ten  months  ago  with  symptoms  of  an 
acute  infection.  This  was  followed  by  dullness,  stupidity 
and  somnolence.  Two  or  three  weeks  later  paralysis  of 
accommodation,  diminution  in  auditory  acuity,  paresis 


198  EPIDEMIC    ENCEPHALITIS 

of  the  right  side  of  the  tongue  and  face,  and  speech 
alteration  appeared.  There'  was  also  stiffness,  clumsiness 
and  retardation  of  movements  of  the  right  arm,  hand, 
and  to  a  less  extent,  of  the  right  leg.  The  somnolence, 
eye  and  ear  symptoms  disappeared,  but  the  other  dis- 
turbances have  remained  to  the  present  with  little 
alteration.  The  present  condition  is  a  hemilateral 
paralysis  agitans  without  tremor,  and  paresis  of  the  right 
side  of  the  face  and  tongue. 


CHAPTER  XXV 


CASE    REPORT    IX 


Mr.  F.  C.  Aged  twenty-one.  Occupation  tailor. 

Admitted  to  hospital  December  15,  1919. 

Chief  Complaint.  Difficulty  in  walking  and  speech, 
duration,  20  months. 

Family  History.  Father  is  living  and  well,  fifty  years 
of  age;  mother,  aged  forty-nine,  is  also  living  and  well. 
Five  sisters  and  five  brothers  are  living  and  well.  No 
tuberculosis,  Bright's  disease,  rheumatism,  heart  trouble 
or  nevous  disorders  in  any  member  of  the  family. 

Personal  History.  Patient  is  single.  He  was  born  in 
Italy;  has  lived  in  the  United  States  four  years.  His  habits 
of  eating  and  sleeping  are  regular.  He  smokes  5  or  6 
cigarettes  a  day;  use  of  alcohol  denied.  Takes  one  cup 
of  coffee  a  day;  no  tea  or  drugs  of  any  kind.  He  has  been 
in  the  habit  of  taking  moderate  daily  exercise.  His  pres- 
ent weight  is  155  pounds;  best  weight — two  years  ago — 
was  166  pounds. 

Previous  Illnesses.  He  has  always  been  robust  and 
healthy.  Does  not  remember  having  any  contagious  or 
infectious  diseases  in  childhood.  Four  years  ago  he  had  a 
short  febrile  attack,  the  particulars  of  which  he  does  not 
know.  He  has  had  no  operations  or  injuries. 

Head:     No  headaches. 

Ears:     No  pain,   difficulty  in   hearing  or  discharge. 

Nose:     Patient  is  not  subject  to  colds  or  catarrh. 

Throat:     No  severe  attacks  of  tonsillitis. 

Teeth:      Have  always  been  kept  in  good  condition. 

199 


200  EPIDEMIC    ENCEPHALITIS 

Respiratory:  He  has  never  had  pneumonia  or  serious 
respiratory  disorders. 

Cardiac:  Has  never  had  excessive  shortness  of  breath 
or  swelling  of  the  feet;  no  palpitation. 

Gastrointestinal:  No  symptoms  of  indigestion;  bowels 
regular. 

Genito-Urinary:  Gonorrhea  and  syphilis  denied  by 
name  and  symptom. 

N euro-Muscular:  No  disorder  before  the  onset  of  the 
present  illness. 

Present  Illness.  During  the  latter  part  of  March,  19 18, 
while  serving  in  the  army,  he  became  severely  constipated , 
there  being  a  period  of  two  weeks  in  which  his  bowels 
did  not  move  at  all  in  spite  of  almost  constant  catharsis. 
Previous  to  this  he  had  had  about  one  stool  a  day.  There 
was  no  nausea,  vomiting  or  abdominal  pain.  He  had 
little  appetite  and  so  ate  practically  nothing  during  this 
period.  Soon  after  the  onset  of  constipation  he  had  severe 
headache  which  was  present  in  all  parts  of  his  head,  and 
was  of  a  boring  character.  On  April  6,  1918,  he  had 
fever  and  at  this  time  developed  diplopia,  constantly 
seeing  two  images  of  every  object  at  which  he  looked. 
In  a  day  or  two  he  became  dizzy,  noisy  and  delirious. 
He  was  confined  to  the  guard-house  where  he  fought 
with  the  other  prisoners  and  made  a  good  deal  of  disturb- 
ance. He  was  put  to  bed  but  had  to  be  restrained  as  he 
was  actively  delirious.  This  condition  continued  for  three 
or  four  days,  after  which  time  his  temperature  became  nor- 
mal, his  diplopia  disappeared  and  the  mental  excitement 
ceased.  At  no  time  was  he  particularly  drowsy,  and  he  was 
never  unconscious.  As  soon  as  he  was  allowed  to  get  out 
of  bed  he  noticed  that  he  had  difficulty  in  walking.  His 
movements  were  slow  and  awkward.  It  was  also  difficult 
for  him  to  feed  himself,  or  to  pick  up  small  articles  with 
his  hands.  On  standing  he  had  a  tendency  to  fall  back- 


STUDIES  OF  SELECTED  CASES        201 

ward,  and  on  walking,  to  fall  forward,  which  would  often 
cause  him  to  run  forward  in  an  endeavor  to  regain  his 
balance.  He  often  found  running  easier  than  walking. 
At  this  time  there  was  a  tremor  which  involved  his  entire 
body  and  consisted  in  a  shaking  of  the  whole  extremity. 
This  was  made  much  worse  by  any  emotional  excitement. 
His  speech  was  so  affected  that  talking  was  slow,  difficult 
and  sometimes  almost  unintelligible.  This  condition  was 
so  marked  that  he  was  supposed  to  be  suffering  from 
bulbar  palsy. 

Since  the  onset  there  has  been  a  gradual  improvement 
in  all  symptoms.  His  speech  is  still  slow  and  monotonous 
but  always  easily  understood.  The  tremor  has  practically 
disappeared  except  when  his  muscles  are  actively  con- 
tracted— being  present  to  some  extent  in  his  legs  on 
standing  or  in  his  arms  if  he  attempts  to  lift  anything, 
or  in  any  emotional  excitement.  He  believes  that  he  is  as 
strong  as  he  ever  was,  but  it  is  difficult  for  him  to  do  any- 
thing, as  his  movements  are  slow  and  clumsy,  and  a  rapid 
succession  of  opposed  movements  impossible.  He  has  no 
difficulty  with  thinking  and  believes  that  his  mind  is  as 
clear  as  formerly.  His  appetite  is  good;  bowels  regular 
and  he  has  normal  sexual  desire.  There  is  no  pain  in  any 
portion  of  his  body,  though  he  is  easily  fatigued  on  any 
exertion. 

PHYSICAL   EXAMINATION 

General  Appearance.  The  patient  is  a  well  developed 
male  of  twenty-one  years,  reclining  quietly  in  bed  in 
apparent  comfort. 

Eyes:  Are  normal;  no  conjunctival  inflammation  or 
petechial  spots. 

Nose:  The  septum  is  deviated  to  the  left.  Nostrils  are 
clear;  there  is  no  nasal  dis(!harge. 

Ears:     Are  negative  to  external  examination. 


202  EPIDEMIC    ENCEPHALITIS 

Mouth:  The  throat  is  not  congested  or  inflamed. 
Tonsils  are  atrophic.  Teeth  are  in  good  repair.  Gums  show 
no  signs  of  pyorrhea.  The  tongue  is  partially  coated. 
It  is  protruded  in  the  midline.  There  is  no  tremor. 

Neck:  Is  held  shghtly  forward  with  some  resistance 
to  passive  movement  but  no  limitation  of  active  move- 
ments. The  thyroid  is  not  visible  or  palpably  enlarged. 
There  are  no  abnormal  pulsations. 

Chest  is  symmetrical;  expansion  is  good  and  equal  on 
the  two  sides. 

Lungs:  Are  resonant  throughout.  Breaths  sounds  are 
normal;  no  rales. 

Heart:  The  outline  is  normal,  the  sounds  of  good 
quality  both  at  the  apex  and  the  base.  Pulse  is  regular; 
rate  76.  Artery  wall  not  palpable.  Blood  pressure:  120-80. 

Abdomen:  Is  symmetrical;  moves  normally  with  res- 
piration. There  is  no  muscular  resistance  or  tenderness. 
The  liver  and  spleen  are  not  felt. 

Extremities:  The  muscles  are  well  developed.  There  is 
no  tremor,  edema  or  deformity. 

Superficial  Lymph  Nodes:  Not  pathologically  enlarged. 

External  Genitalia:     Well  developed;  normal. 

Skin  is  soft  and  moist  with  no  eruptions. 

Hair  is  normal  with  masculine  type  of  cHstribution. 

Temperature  98.4°.  Respiration  20.  Weight  Ml}^ 
pounds. 

LABORATORY    EXAMINATION 

Blood  Count:     December  16,  1919. 

Red  blood  cells 5,140,000 

Hemoglobin 90  per  cent. 

White  blood  cells 11,800 

Polymorphonuclear  leucocytes  71  per  cent. 

Small  lymphocytes 21  per  cent. 

Large  lymphocytes 6  per  cent. 

Transitionals 2  per  cent. 


STUDIES  OF  SELECTED  CASES        203 

Throat  Culture:     December  16,  1919. 
No  diphtheria  organisms. 

Lumbar  Puncture:     December  16,  1919. 

Amount 12  c.c. 

Appearance Perfectly  clear 

Pressure Normal 

Cells 2  lymphocytes 

Wassermann 2  c.c.      1  c.c.      .2  c.c.     .6  c.c. 

Alcohol  antigen Neg.       Neg.       Neg.       Neg. 

Cholesterin  antigen .  Neg.       Neg.       Neg.       Neg. 

Colloidal  gold OOOOOOOOOfM) 

Urine  Examination:     December  17,  1919. 

Specific  gravity 1.032 

Reaction Acid 

Color Amber 

Precipitate None 

Albumin None 

Glucose None 

Microscopical  examination No  casts,  crystals  or  cells 

NEUROLOGICAL  EXAMINATION:  DECEMBER   18,    1919 

Voluntary  Motor  System.  Abnormal  Attitudes  and 
Deformities.  The  patient  is  sitting  quietly  in  a  chair 
without  evident  signs  of  pain  or  discomfort.  The  facies 
are  absolutely  expressionless;  all  lines  and  furrows  from 
the  forehead  and  face  are  obliterated.  The  lower  eye- 
lids sag.  The  mouth  is  closed.  On  standing  the  head  and 
shoulders  are  bent  forward,  the  arms  are  slightly  ab- 
ducted at  the  wrists,  fingers  partially  closed  with  each 
thumb  in  contact  with  the  terminal  phalanx  of  the 
index  finger.  The  legs  are  not  straight  but  are  slightly 
flexed  at  the  hips  and  knees. 

Gait.  On  walking  he  starts  out  slowly,  taking  rather 
large  steps  but  without  lifting  his  feet  far  fi'om  the  floor. 


204 


EPIDEMIC    ENCEPHALITIS 


Fig,  42.— Case  IX.  Standing 
Attitude;  Showing  Slight  Tremor 
of  Legs. 


Soon  the  steps  become 
shorter  and  the  gait  ac- 
celerated .  He  turns 
around  slowly,  the  move- 
ments being  slow  and 
awkward. 

C  oordination.  On 
standing  with  his  feet 
together  he  has  a  ten- 
dency to  fall  backward. 
There  is  also  moderate 
swaying  laterally  and 
forward,  which  is  no  more 
marked  when  the  eyes  are 
closed. 

Non-e  quilibratory. 
Finger-to-nose,  pointing 
and  past  pointing,  heel- 
to-knee-and-a  1  o  n  g-  s  h  i  n 
tests  are  performed  slowly 
but  with  normal  precision. 
There  is  no  dysmetria. 
Rapid  pronation  and 
supination  of  either  arm 
is  impossible. 

Skilled  Acts.  There  is 
no  dyspraxia  or  aphasia. 
The  speech  is  slow,  mono- 
tonous and  rather  feeble. 
Handwriting,  he  says,  is 
smaller  than  before  the 
illness  commenced,  but 
not  affected  in  any  other 
way. 


STUDIES    OF    SELECTED    CASES 


205 


Reflexes 

Deep  Right  Left 

Jaw 1  1 

Pectoral 2  2 

Biceps 2  2 

Triceps 1  1 

Radial 2  2 

Ulnar 1  1 

Suprapatellar Absent  Absent 

Patellar 3  3 

Achilles 1  1 

Superficial 

Supra-umbilical Present  Present 

Suprapubic Present  Present 

Upper  lateral  abdominal Present  Present 

Lower  lateral  abdominal Present  Present 

Plantar  flexion Present  Present 

Babinski  and  modifications Al)sent  Absent 


Abnormal  Involuntary  Movements.  The  patient  states 
that  when  he  is  excited  or  angry,  a  general  coarse  tremor 
is  produced  which  affects  the  arms  and  Hmbs  on  both 
sides.  In  the  examination  none  is  noted  in  the  arms, 
but  when  standing  there  is  a  fine  tremor  of  both  legs. 
(This  is  evident  in  the  photograph.) 

Muscle  Strength.  Opposed  and  unopposed  movements 
of  the  neck,  shoulder,  arm,  forearm,  hand,  thigh,  leg 
and  foot  show  normal  strength  on  each  side. 

Muscle  Status.  Volume:  All  muscles  are  well  de- 
veloped, of  normal  contour  and  consistence.  The  tone  is 
increased,  there  being  a  rigidity  in  the  muscles  of  all 
four  extremities.  There  is  resistance  to  passive  move- 
ment with  greater  resistance  in  flexor  muscles  than  in 
extensor.  Supination  of  the  forearm  is  resisted  more  than 
pronation.  This  resistance  to  passive  movement  is  not 
uniform,  but  shows  the  phenomenon  of  cog-wheel  release. 
There  is  some  degree  of  flexibilitas  cerea,  tlu^  arms  being 


206  EPIDEMIC    ENCEPHALITIS 

held  for  some  time  in  any  position  in  which  they  are 
placed. 

Ahnormal  Associated  Movemeyits.     Not  tested. 
Nerve  Status.     No  observation. 


Fig.  43. — Case  IX.     Showing  Mask-like  Expression  of  Face. 

General  Sensory.  Touch,  pain,  temperature,  vibrator}^, 
pressure,  muscle  tendon  sense  and  stereognositic  per- 
ception are  normal. 


STUDIES  OF  SELECTED  CASES        207 

Cranial  Nerves  and  Head.  Olfactory  Nerve  and 
Nose.     Smell  is  normal  in  each  nostril. 

Optic  and  Oculamoior  Apparatus.  Visual  acuity  is 
normal  in  each  eye.  Perimetry,  roughly  tested,  shows  no 


Fig.  44. — Case  IX.     Showing  Facial  Weakness  on  Attempting 

to  Smile. 

contraction  of  any  field.  Eyegrounds:  Both  discs  are 
well  outlined.  There  are  no  hemorrhages.  The  vessel 
walls  appear  normal.  The  pupils  are  ecjual  and  regular; 


208  EPIDEMIC    ENCEPHALITIS 

they  react  actively  to  light  and  on  accommodation. 
The  palpebral  fissures  are  increased  in  size,  due  largely  to 
lagging  of  the  lower  lid.  The  upper  lid  covers  the  upper 
portion  of  the  cornea  while  there  is  a  broad  band  of 
sclera  visible  below  the  lower  portion  of  the  cornea. 
There  is  also  a  slight  eversion  of  the  lower  lids.  There  is 
no  perceptible  exophthalmos,  enophthalmos  or  ptosis. 
Strabismus  is  absent.  There  is  no  nystagmus. 

Acoustic  Nerve  and  Ear.  Hearing  is  normal  in  each 
ear.  Air  conduction  is  greater  than  bone. 

Trigeminus  Nerve  and  Mouth.  Movements  of  the 
jaw  are  normal  in  all  directions.  The  corneal  reflex  is 
present.  There  is  no  ansesthesia  in  the  region  supplied 
by  the  5th  nerve. 

Facial  Nerve  and  Face.  There  is  weakness  of  the  face 
on  each  side,  more  marked  on  the  left,  retraction  of  the 
mouth  being  much  less  on  this  side.  Both  eyes  can  be 
closed  tightly.  Taste  on  the  anterior  portion  of  the 
tongue  is  normal. 

Glossopharyngeus  and  Vagus  Nerves,  Pharynx  and 
Larynx.  The  tip  of  the  uvula  deviates  to  the  left,  but 
the  palatal  arches  are  symmetrical  and  move  normally 
during  phonation.  The  palatal  and  pharyngeal  reflexes 
are  active.  There  is  no  difficulty  in  swallowing. 

Spinal  Accessory  Nerve.  There  is  no  sign  of  weakness 
of  either  sternomastoid  or  trapezius  muscles. 

Hypoglossus  Nerve  and  Tongue.  The  tongue  is  pro- 
truded in  the  midline.  Its  movements  in  all  directions  are 
equal.  The  trophic  status  is  normal. 

SUMMARY 

The  onset  was  twenty  months  ago  with  obstipation  for 
two  weeks  followed  suddcaily  by  fever,  diplopia,  excitement 


STUDIES  OF  SELECTED  CASES        209 

and  delirium.  These  symptoms  disappeared  in  three  to  four 
days,  and  then  his  movements  were  slow  and  awkward  and 
speech  so  difficult  that  it  was  at  times  unintelligible. 
Since  this  time  there  has  been  a  gradual  improvement 
in  ease  of  movement  and  in  his  voice.  Examination  at 
present  shows  a  typical  Parkinson  syndrome,  without 
the  tremor,  and  a  facial  diplegia.  The  case  is  of  especial 
interest  because  it  is,  I  believe,  the  only  case  reported 
to  date  of  long  duration,  the  symptoms  continuing  for 
nearly  two  years. 


CHAPTER  XXVI 


CASE    REPORT  X 


J.  W.  W.,  born  in  Scotland.  Aged  forty-three,  mar- 
ried. Occupation:  Electrical  engineer. 

Admitted  to  the  hospital  April  4,  1919. 

Chief  Complaint.  Trembling  of  the  limbs  and  con- 
tinuous sleeping  for  three  and  a  half  months. 

Family  History.  Mother  living,  but  of  feeble  health, 
aged  eighty.  Father  died  at  the  age  of  fifty  from  cancer 
of  the  rectum.  Four  brothers  and  five  sisters  all  living  and 
well.  No  history  of  tuberculosis  or  other  chronic  diseases 
in  the  family. 

Past  History.  Patient  has  always  been  well.  He  is 
subject  to  headaches,  never  very  severe.  He  has  had  no 
gastrointestinal  disturbances.  He  denies  venereal  diseases 
by  name  and  symptom.  Last  October  he  had  influenza, 
but  made  a  good  recovery.  He  has  always  been  active 
and  of  a  rather  nervous  temperament.  He  does  not 
remember  any  acute  infectious  diseases  in  childhood. 

Personal  History.  Patient  is  an  electrician  and 
inventor.  He  is  married;  his  wife  is  living  and  well. 
He  had  two  children;  one  died  through  instrumental 
labor.  His  wife  had  one  abortion  during  an  attack  of 
pneumonia.  He  eats  his  meals  regularl}^,  but  sleeps  very 
irregularly,  often  sleeping  but  a  few  hours  at  night,  as 
he  is  in  the  habit  of  working  late  over  inventions.  He 
denies  the  use  of  alcoholic  stimulants.  He  smokes  about 
six  pipes  of  tol)acco  a  day.  He  has  never  used  any  drugs. 

210 


STUDIES  OF  SELECTED  CASES        211 

Present  Illness.  Three  and  a  half  months  ago  he 
began  to  be  very  nervous  and  irritable.  At  the  same  time 
he  developed  a  tremor  of  his  hands.  His  ears  pained  him 
for  a  week;  this  was  followed  by  severe  headache  lasting 
two  or  three  days.  He  stopped  work  and  his  physician 
ordered  him  to  go  to  l)ed.  The  first  night  he  could  not 
sleep.  The  next  night  he  fell  asleep  and  for  three  weeks 
he  slept  almost  all  the  time.  It  was  possible  to  arouse  him 
enough  to  take  food,  but  he  would  frequently  fall  asleep 
while  taking  it  or  while  being  bathed.  For  the  first  two 
weeks  he  talked  continuously  during  his  sleep.  When 
arou.sed  he  seemed  rational,  but  his  talk  during  his  sleep 
was  entirely  irrational.  During  the  weeks  he  was  sleep- 
ing he  had  a  constant  fever,  at  times  as  high  as  104°. 
He  had  no  vomiting  or  convulsions.  His  neck  was  not 
stiff.  He  had  no  paralyses  of  any  muscles.  After  a  time 
he  gradually  grew  better,  got  up  and  seemed  fairlv  well. 
He  was  not  nervous  or  irritable,  but  somewhat  indifferent 
to  what  was  going  on  about  him. 

Two  weeks  ago  his  left  arm  began  to  twitch,  with  no 
particular  movement,  but  flexion  of  the  forearm  was  more 
frequent  than  smy  other.  A  few  daj's  later  he  began  to 
have  irregular  movements  of  his  head.  At  this  time  his 
left  leg  seemed  weak.  He  could  lift  it  but  dragged  it  in 
walking.  Soon  the  left  leg  also  began  the  same  irregular 
involuntary  movements  as  in  the  arm  and  head.  About 
this  time  the  left  upper  eyelid  drooped  and  he  was  unable 
to  lift  it.  During  the  last  four  or  five  days  the  right  eyelid 
has  become  the  same  as  the  left.  There  have  never  been 
any  convulsive  movements  in  the  right  arm  or  leg,  while 
the  movements  of  the  left  side  have  steadily  grown  worse; 
that  is,  they  are  almost  constantly  present  when  he  is 
awake,  but  are  made  worse  bj^  excitement,  and  at  some 


212 


EPIDEMIC    ENCEPHALITIS 


A  Series  of  Photographs  Illustrating  the  Progressive 
Phases  of  Movement  and  Facial  Expression  through 
WHICH  the  Patient  is  Constantly  Passing 


Fig.  45. — Case  X.     No.  1. 


Fig.  -IG.— Case  X.     No.  2. 


STUDIES  OF  SELECTED  CASES        213 


I'iG.  47— Case  X.  No.  ;j. 


FiQ.  48.— Case  X.  No.  4. 


214 


EPIDEMIC    ENCEPHALITIS 


times  of  the  day  they  seem  worse  than  at  others.  His 
speech  was  normal  until  three  weeks  ago  when  a  slight 
''slur"  was  noted.  During  the  last  few  days  he  feels  that 


Fig.  49.— Cask  X.     No.  5. 


his  speech  is  more  involved,  but  it  seems  to  him  to  be 
more  as  though  he  did  not  have  the  strength  to  talk. 
At  times  during  the  last  two  weeks  he  has  been  irrational 
and  seems  to  be  steadily  growing  moi-e  stuporous.  He 


STUDIES  OF  SELECTED  CASES 


215 


has  had  no  incontinence  of  urine  or  feces.  His  appetite 
seems  good. 


Fig.  50. — Case  X.     No.  6. 


Two  weeks  before  admission  he  had  an  eruption  around 
the  waist  Hne  which  he  calls  "hives."  The  eruption 
appeared  in  streaks  and  was  accompanied  by  itching. 
It  disappeared  in  a  few  days. 


216 


EPIDEMIC    ENCEPHALITIS 


GENERAL    PHYSICAL   EXAMINATION 

General  Appearance.     A  middle-aged  man,  well  de- 
veloped and  nourished,  lying  dorsally  in  bed  with  his 


Fig.  51. — Case  X.     2so.  7. 


eyes  closed.  He  does  not  appear  to  be  in  pain.  At  frequent 
intervals  there  is  a  spasmodic  movement  of  the  left 
arm,  head  and  left  leg.  The  left  forearm  is  flexed  on  the 


STUDIES  OF  SELECTED  CASES        217 

arm.  The  left  hand  is  tightly  closed.  His  speech  is  rather 
indistinct.  His  mouth  appears  drawn  to  the  left  when 
smiling. 


52.— Case  X. 


Head  is  well  shaped.  There  are  no  tender  areas  over 
the  skull,  mastoid  or  sinuses.  The  neck  is  not  stiff.  The 
eyes  are  both  closed;  the  patient  is  unable  to  open  the 
left  eye  but  can  raise  the  right  lid  about  half  way.  The 


218  EPIDEMIC    ENCEPHALITIS 

pupils  are  slightly  dilated,  clear  and  regular.  They  react 
very  sluggishly  to  light.  There  is  a  marked  nystagmus  to 
the  left.  The  fundi  appear  normal.  The  nose  is  negative 
to  external  examination;  there  is  no  discharge.  The  ears 
are  negative;  the  ear  drums  appear  normal.  Mouth: 
The  lips  are  not  cyanotic.  The  tongue  is  heavily  coated. 
The  teeth  in  the  upper  jaw  are  false;  in  the  lower  jaw 
they  are  poor.  There  is  a  moderate  pj^orrhea.  Throat. 
The  tonsils  are  not  enlarged  or  inflamed. 

Thorax  is  well  developed;  expansion  is  equal  on  the 
two  sides  and  symmetrical. 


Fig.  53. — Case  X.  General  Position  U?ually  Assumed.  Head 
Thrown  Back  and  Inclined  to  the  Left.  Left  Arm  Flexed  and 
Left  Hand  Closed.  Permanent  Dorsal  Flexion  of  the  Toes  on  the 
Right  Side. 

*S'^-m.  The  axillary  region  of  the  left  side  seems  more 
wrinkled  and  lax  than  on  the  right. 

Lungs.  Resonance  is  normal  throughout;  there  is  no 
alteration  in  breath  or  voice  sounds.  No  rales  are  heard. 

Heart.  The  apex  is  not  seen  or  definitely  felt.  The 
heart  outline  is  normal,  the  left  limit  of  dullness  being 
10  cm.  to  the  left  of  the  mid-line  in  the  fifth  interspace. 
There  are  no  murmurs.  The  action  is  regular.  Rate  100. 
The  pulse  is  of  good  ciuality.  Blood  pressure  114 — 75. 

Abdomen.  There  are  no  areas  of  tenderness.  The  liver 
dullness  extends  from  the  fourth  interspace  to  the  costal 


STUDIES  OF  SELECTED  CASES        210 

margin.  The  liver  edge  is  just  palpable.  The  whole 
abdomen  is  held  rather  rigidly,  but  there  is  no  localized 
muscular  spasm. 

External  Genitalia  appear  normal. 

Superficial  Lymph  Nodes  are  not  pathologically  enlarged. 

Extremities.  The  left  arm  is  held  rather  spastically 
flexed  at  the  elbow.  The  left  leg  is  slightly  spastic.  There 
is  tenderness  on  deep  pressure  over  the  muscles  of  the 
left  calf  and  the  left  forearm.  There  is  some  hyperesthesia 
over  the  left  forearm. 

Blood  Examination:    April  IG,  1919. 

Red  blood  cells 5,300,000 

Hemoglobin 70  per  cent. 

White  blood  cells 15,800 

Polymorphonuclear  leucocytes. .  8G  per  cent. 

Large  lymphocytes 6  per  cent. 

Small  lymphocytes 6  per  cent. 

Transitionals 1  per  cent. 

Eosinophiles 1  per  cent. 

Blood  Wassermann:     April  17,   1919. 

Alcohol  antigen Negative 

Cholesterin  antigen Negative 

Blood  Culture:     April  17,   1919. 

No  growth 
Spinal  Fluid:     April  17,  1919. 

Amount 15  c.c. 

Appearance Clear,  colorless 

Pressure Normal 

Globulin Trace 

Lymphocytes 260   (the   interne  who  made   this 

count  does  not  believe  it  is  correct) 

Culture Negative 

Wassermann 2  c.c.      1  c.c.      .6  c.c.     .2  c.c. 

Alcohol Neg.       Neg.       Neg.       Neg. 

Cholesterin Neg.       Neg.       Neg.       Neg. 


220  EPIDEMIC    ENCEPHALITIS 

Blood  Examination:    April  21,  1919. 

White  blood  cells 13,200 

Polyraorphonuclear  leucocytes 74  per  cent 

Large  lymphocytes 7  per  cent 

Small  Ij'mphocj^tes 18  per  cent 

Transitionals 1  per  cent 

Spinal  Fluid:    April  21,  1919. 

Pressure Apparently  decreased 

Amount 10  c.c. 

Appearance Slightly  blood  tinged 

Globulin Present 

Cell  count • 23  lymphocytes 

Colloidal  gold  curve 1,  2,  2,  3,  4,  3,  2,  1,  0,  0 

Ui'ine  Examination:    April  22,  1919. 

Specific  gravity 1.029 

Reaction Acid 

Color Dark  amber 

Turbidity None 

Precipitate Slight  flocculent 

Albumin None 

Glucose None 

Microscopical  exam Many  amorphous  urates 

Blood  Examination:    May  5,  1919. 

White  blood  cells 14,600 

Polymorphonuclear  leucocytes 73  per  cent. 

Large  lymphocytes 9  per  cent. 

Small  lymphocytes 17  per  cent. 

Transitionals 1  per  cent. 

NEUROLOGICAL    EXAMINATION:    APRIL    16,    1919 

Voluntary  Motor  System.  Attitudes.  The  patient 
is  lying  dorsally  in  bed;  his  head  is  thrown  back  and 
inclined  to  the  left.  Both  eyes  are  closed;  the  left  one 
appears  more  tightly  shut  than  the  right.  His  mouth  is 
drawn  over  to  the  left  side.  The  head  is  not  held  still 


STUDIES  OF  SELECTED  CASES        221 

but'is  rotated  from  side  to  side  as  though  he  were  trying 
to  bore  a  hole  in  the  pillow.  His  left  arm  is  flexed  at  the 
elbow  and  the  fist  is  firmly  clenched.  The  arm  is  con- 
stantly moved  about,  but  the  flexed  position  is  generally 
maintained.  The  left  leg  is  drawn  up;  the  thigh  is  flexed 
at  the  hip  and  the  leg  at  the  knee.  The  limb  is  also  in 
almost  constant  motion,  being  moved  about  in  all  direc- 
tions. The  right  side  of  the  face  is  somewhat  flattened; 
the  right  arm  and  leg  are  usually  extended  and  are  moved 
about  somewhat,  but  are  not  in  as  continuous  motion  as 
are  the  extremities  of  the  left  side.  It  is  possible  for  him 
to  hold  his  hmbs  and  head  quiet  for  about  thirty  seconds 
if  he  makes  a  strong  effort,  but  he  is  unable  to  inhibit  the 
movement  for  a  longer  period.  He  is  able  to  open  the  right 
eye  to  about  half  the  normal  extent,  but  cannot  open  the 
left  one  at  all.  Both  eyes  are  drawn  over  to  the  left  and 
there  is  nystagmus  to  that  side.  The  mouth  is  drawn  over 
more  to  the  left  and  he  is  constantly  making  grimacing 
expressions  which  vary  from  a  pouting  of  his  lips,  a  roll- 
ing of  his  lower  lip,  to  a  forced  smile.  At  other  times  there 
is  a  period  of  uncontrollable  laughter.  Forcible  attempts 
passively  to  open  his  left  hand  and  to  extend  his  left  arm 
are  painful. 

Gait.     The  patient  is  unable  to  stand  or  walk. 

Coordination.  Finger-to-nose  and  heel-to-knee  tests 
on  the  right  side  are  well  performed.  On  the  left  side  the 
hand  cannot  be  opened,  so  he  attempts  to  touch  the 
end  of  his  nose  with  his  knuckle.  This  is  accomplished  by 
coarse,  irregular,  rotary  movements  which  end  after 
considerable  difficulty  in  placing  the  knuckle  accurately 
on  the  tip  of  the  nose.  The  incoordination  becomes  less 
as  the  hand  nears  the  nose.  The  heel-to-knee  test  is 
carried  out  with  the  same  difficulty  on  the  left  side,  but 
in  the  end  is  accomplished  with  fair  ])r(!cisi()M.  Thcie  is  a 


222 


EPIDEMIC    ENCEPHALITIS 


marked  retardation  of  successive  movements  of  prona- 
tion and  supination  on  the  left  side;  but  they  are  normal 
on  the  right. 

Skilled  Acts.  He  is  able  to  salute  perfectly  with  the 
right  hand  and  makes  a  fairly  normal  attempt  to  do  so 
with  the  left  arm,  though  the  fist  is  closed  and  it  is  accom- 
panied by  jerky  movements.  Speech  is  slightly  slurred. 

Reflexes: 

Deep  Right  Left 

Jaw 1  1 

Pectoral 1  1 

Biceps 2  1 

Triceps 2  1 

Wrist 1  1 

Radial 1  1 

Ulnar 1  1 

Patellar 3  1 

Suprapatellar 3  1 

Achilles 3  1 

Superficial 

Ciliospinal Absent  Absent 

Supra-umbilical Present  Present 

Suprapubic Present  Present 

Upper  lateral  abdominal Present  Present 

Lower  lateral  abdominal Present  Present 

Plantar  flexion Absent  Present 

Babinski Present  Absent 

Chaddock Present  Absent 

Oppenheim Present  Absent 

Gordon Present  Absent 

Schafer Present  Absent 


There  is  transient  patellar  and  ankle  clonus  on  the 
right  side. 

Abnormal  Involuntary  Movements.  These  have  been 
described  under  the  head  of  general  appearance  and  con- 
sist of  a  choreo-athetosis  which  is  limited  to  the  left  side 
and  most  marked  in  the  head,  face  and  arm. 


STUDIES  OF  SELECTED  CASES        223 

Muscle  Strength.  This  is  rather  difficult  to  tost  on 
account  of  the  constant  movement  of  the  left  side,  but 
there  seems  to  be  no  definite  loss  of  strength  on  either 
side. 

Muscle  Status.  There  is  no  apparent  loss  in  volume  or 
change  in  contour  of  any  portion  of  the  body  (except 
for  the  flattening  of  the  right  side  of  the  face) . 

Abnormal  Associated  Movements.     None  are  present. 

Nerve  Status.     Nothing  abnormal  noted. 

General  Sensory.  Pain,  temperature,  vibratory, 
muscle-tendon  sense  and  stereognostic  perception  are  all 
normal.  There  is  some  hyperaesthesia  over  the  left  fore- 
arm and  hand  and  distinct  tenderness  on  deep  pressure 
over  the  muscles  of  the  left  forearm,  left  thigh  and  calf. 

Subjective  Sensibility.  He  complains  of  severe  burning 
pains  in  the  left  forearm  and  hand  which  are  present 
most  of  the  time.  Passive  extension  of  the  fingers  or  force- 
ful extension  of  the  left  wrist  cause  him  to  cry  out  with 
pain. 

Cranial  Nerves  and  Head.  Olfactory  Nerve  and 
Nose.     Normal. 

Optic  and  Oculomotor  Apparatus.  Visual  acuity 
cannot  be  accurately  estimated.  Perimetry,  roughly 
tested,  seems  normal.  (The  patient  was  seen  by  Dr.  Tilney 
before  his  admission  to  the  hospital  and  at  that  time  had 
a  left  homonymous  hemianopsia.)  Eyegrounds:  Both 
optic  disks  are  normal;  there  are  no  hemorrhages.  The 
pupils  are  moderately  contracted,  regular,  equal;  reac- 
tion to  light  and  on  accommodation  is  limited.  The  left 
eye  is  entirely  closed;  the  right  one  is  often  closed  but 
may  be  opened  about  half  way.  There  is  no  evident 
exophthalmos  or  enophthalmos.  There  is  a  deviation  of 
both  eyes  to  the  left  and  a  limitation  in  his  ability 
to  move  them  to  the  right.  There  is  a  moderate  horizontal 
nystagmus  with  a  slow  movement  to  the  left. 


224  EPIDEMIC    ENCEPHALITIS 

Acoustic  Nerve  and  Ear.  The  hearing  is  normal  on 
both  sides.  Air  conduction  is  greater  than  bone  on  each 
side. 

Trigeminus  Nerve  and  Mouth.  The  jaw  reflexes  are 
normal.  Both  conjunctival  reflexes  are  present.  There  is 
no  evident  weakness  of  any  of  the  muscles  of  mastication. 

Facial  Nerves  and  Face.  Taste  on  the  anterior  two- 
thirds  of  the  tongue  is  normal.  There  is  a  slight  flattening 
of  the  lower  portion  of  the  face  on  the  right  side. 

The  Glossopharyngeus,  Vagus  Nerve,  Pharynx  and 
Larynx.  The  uvula  is  in  the  median  position.  The  palatal 
and  pharyngeal  reflexes  are  normal.  The  quality  of  the 
voice  is  normal.  There  is  no  difficulty  in  swallowing. 

Spinal  Accessory  Nerve.  There  is  no  evident  weakness 
of  either  sternomastoid  or  trapezius  muscle. 

The  Hypoglossus  Nerve  and  Tongue.'  The  tongue  is 
protruded  in  the  mid-line,  and  there  is  no  trophic  dis- 
turbance, tremor  or  twitching. 

Mentally  he  is  at  present  surprisingly  clear  and  bright, 
answering  questions  promptly  and  correctly  and  showing 
a  keen  sense  of  humor.  At  times  he  has  delusions,  believing 
his  attendants  are  trying  to  starve  him  and  not  wanting 
him  to  have  water  or  to  see  his  wife.  Occasionally  at 
night  he  is  quite  delirious,  talking  loudly  and  incoherently 
and  attempting  to  get  out  of  bed.  He  is  perfectly  oriented, 
but  his  memory  for  recent  events  is  quite  faulty.  There  is 
marked  emotional  instability  resulting  in  uncontrollable 
laughter  or  crying.  He  shows  interest  in  the  condition 
of  the  patients  in  the  beds  next  to  his,  and  cried  at  the 
sight  of  one  of  these  patients  greeting  his  wife.  He  is 
surprisingly  indifl"erent  to  his  own  condition  and  if 
questioned  about  it  expresses  the  feeling  that  he  will 
entirely  recover.  The  constant  movement  and  contortion 
of  his  head,  arm  and  leg  do  not  seem  to  tire  or  distress 
him  very  nuich. 


STUDIES    OF    SELECTED    CASES  225 

SPECIAL   EXAMINATIONS    AND    CLINICAL   NOTES 

Eye  examination,  April  18,  1919  (bj-^  Dr.  Schoenberg) : 

1.  The  patient  keeps  both  eyes  closed.  If  told  to  open 
them  he  does  so,  but  shows  a  slight  ptosis  on  the  right 
and  a  marked  ptosis  on  the  left. 

2.  Position  of  the  eyes  is  that  of  conjugate  deviation 
to  the  left  of  an  irritative  nature.  Motility  is  good  up, 
down  and  to  the  left;  slightly  insufficient  to  the  right. 
There  is  slight  insufficiency  of  convergence. 

3.  Pupils  dilate  to  dark,  but  the  reaction  to  light  and 
on  accommodation  is  very  much  reduced. 

4.  Corneal  sensibility  is  normal. 

5.  Fundi  normal. 

6.  Vision  cannot  be  taken  on  account  of  the  patient's 
general  condition. 

Eye  examination,  April  22,  1919  (by  Dr.  Schoenberg): 

1.  Vision  is  about  10/15  in  the  right  eye;  10/30  in  the 
left. 

2.  Patient  observes  color — red  and  green — in  each  eye. 

3.  Conjugate  deviation  to  the  left  has  disappeared 
but  there  is  still  slight  difficulty  in  looking  to  the  right. 

4.  There  is  marked  insufficiency  of  convergence. 

5.  Fields  of  vision  roughly  taken  are  normal.  No 
hemianopsia. 

April  22,  1919.  Since  the  patient  has  been  in  the  hos- 
pital he  has  been  irrational  the  greater  part  of  the  time. 
He  has  delusions,  especially  in  regard  to  the  medical 
attendants,  believing  that  they  are  persecuting  him  and 
do  not  wish  him  to  get  well.  Two  days  ago  he  would  not 
remain  in  bed  and  had  to  be  restrained.  Yesterday  he 
seemed  more  normal  and  easier  to  manage,  but  to-day 
he  is  quite  obstinate  and  refuses  all  forms  of  medication. 
The  symptoms  have  remained  practically  the  same  for 

15 


226  EPIDEMIC    ENCEPHALITIS 

the  past  few  days,  the  temperature  ranging  from  100° 
to  101°.  He  has  complained  of  no  pain.  He  had  to  be 
catheterized  once.  The  choreo-athetotic  movements  of 
the  head,  left  arm  and  leg  continue.  These  are  more  vio- 
lent when  he  becomes  excited,  and  disappear  entirely 
when  he  is  asleep.  Occasionally  when  drowsy  he  shows 
signs  of  catatonia  holding  his  arms  in  the  air  and  his 
mouth  open  and  remaining  in  this  position  for  several 
minutes. 

He  is  now  able  to  open  both  eyes  to  some  extent,  the 
right  more  than  the  left. 

April  25,  1919.  The  movements  of  the  left  side  continue 
without  apparent  change.  Mentally  he  is  much  clearer 
and  more  reasonable.  At  times  he  has  a  good  deal  of 
pain  in  the  left  arm  and  leg.  He  is  now  able  to  open  both 
eyes  fully,  though  he  very  often  keeps  the  left  one  en- 
tirely closed  and  the  right  one  partly  so. 

May  5,  1919.  The  patient  has  been  sitting  up  in  a 
chair  for  about  one-half  hour  at  a  time  for  the  past  few 
days.  In  general,  he  seems  somewhat  better.  Often  his 
movements  are  not  as  violent  as  before,  but  they  are 
made  worse  by  any  excitement.  He  has  a  distinct  an- 
tipathy to  popular  music  and  if  it  is  played  on  the  pho- 
nograph in  the  ward  he  becomes  verj'  excited.  He  enjoys 
classical  music,  and  if  it  has  any  effect  upon  him  it  is  a 
quieting  one. 

May  15,  1919.  The  patient  has  improved  very  much 
since  the  lastnote.  He  is  almost  constantly  entirely  ration- 
al. At  night  he  sleeps  well,  is  quiet  and  has  no  delirium. 
The  movements  of  the  left  side  are  much  less  violent 
and  it  is  possible  for  him  to  inhibit  them  entirely  by  a 
strong  effort  for  a  period  of  about  two  minutes.  He  is 
able  to  extend  the  fingers  of  his  left  hand  fully  except  for 
the  little  finger  which  remains  partially  flexed.  Dysaes- 


STUDIES  OF  SELECTED  CASES        227 

thesia  is  present  on  the  left  side  but  is  not  as  pronounced 
and  troublesome  as  formerly.  There  is  no  ptosis  on  either 
side.  The  nystagmus  has  disappeared  and  the  pupillary 
reactions  are  normal.  He  is  able  to  read  the  larger  print 
in  the  newspaper,  but  finds  that  the  focal  distance  for 
small  print  is  about  double  what  it  was  before  his  illness 
commenced.  The  visual  fields  are  not  contracted.  The 
weakness  of  the  right  side  of  his  face  is  difficult  to  demon- 
strate and  has  practicality  disappeared.  The  patellar  and 
Achilles  reflexes  on  the  right  side  remain  active,  and  the 
Babinski  and  its  modifications  are  still  present,  though 
his  great  toe  is  no  longer  constantly  in  the  positioii  of 
dorsal  flexion.  The  left  hemiataxia  is  still  marked. 

January  10,  1920.  During  the  past  seven  months  there 
has  been  a  slow  but  steady  improvement.  The  movement 
of  the  head  and  arm  still  continues,  but  less  violently. 
The  head  is  held  nearly  erect,  but  during  the  movement 
it  is  drawn  more  to  the  left  side  than  to  the  right.  The 
facial  grimacing  has  almost  entirely  disappeared,  though 
at  times  there  is  a  tendency  to  protrude  and  evert  the 
lower  lip.  There  is  a  rhythmical  forward  and  backward 
movement  of  the  tongue.  The  tip  is  not  protruded  from 
the  mouth  but  is  pressed  against  the  lower  teeth  and  the 
tongue  everted  so  that  the  dorsum  strikes  against  the 
upper  teeth.  This  does  not  interfere  with  speech  as  is 
ceases  with  voluntary  movement.  Difficultj^  in  swallow- 
ing is  present  to  some  extent,  but  is  due  to  a  drynest 
of  the  throat  rather  than  to  any  motor  weakness. 

Unless  the  left  arm  is  voluntarily  placed  in  some  other 
position,  it  is  held  with  the  elbow  sharply  flexed,  the 
wrist  flexed  and  the  fingers  closed,  the  hand  being  pressed 
against  the  chest  in  the  pectoral  region.  It  is  possible  to 
open  the  hand  fully  and  hold  it  open  for  a  minute  or  two, 
but  as  soon  as  the  voluntary'  effort  ceases,  it  closes  again 


228  EPIDEMIC    ENCEPHALITIS 

tightly.  Passive  extension  of  the  fingers  is  no  longer 
painful.  Walking  is  accomplished  without  difficulty, 
and  the  patient  frequently  takes  walks  of  a  mile  or  more. 
There  is  a  tendency  to  toe  in  with  the  left  foot  which 
is  more  pronounced  when  he  is  fatigued.  While  he  is 
walking  the  movement  of  the  arm  and  head  is  lessened. 
On  sitting  down,  if  one  knee  is  crossed  over  the  other 
there  is  a  rhythmical  dorsal  flexion  of  the  foot.  This 
is  present  on  both  sides  but  is  more  pronounced  on  the 
left.  To  stop  it  he  frequently  sits  with  his  thighs  abducted, 
his  feet  inverted,  and  the  outer  margin  of  the  right  foot 
on  the  inner  side  of  the  left  one. 

His  vision  now  is  normal,  paralysis  of  accommodation 
having  completely  disappeared. 

The  treatment  he  has  received  has  been  entirely 
symptomatic,  consisting  of  sedatives  administered  at 
irregular  intervals  as  required.  Chloral  hydrate  and 
paraldehyde  have  been  more  quieting  than  bromides  or 
drugs  of  the  veronal  series. 

SUMMARY 

The  salient  points  in  the  history  are  the  gradual  onset 
of  an  illness  characterized  by  marked  stupor,  somnolence, 
delirium  and  fever,  later  by  choreo-athetotic  movements 
of  the  left  arm,  burning,  prickling  sensations  in  the  left 
arm  and  leg,  weakness  of  the  left  leg,  ptosis  of  the  left 
eye,  involuntary  movements  of  the  head  and  left  side  of 
the  face,  ptosis  of  the  right  eye,  involuntary  movements 
of  the  left  leg;  then  lessening  of  the  ptosis  in  the  right 
and  then  in  the  left  eye,  return  of  normal  strength  in  the 
left  leg,  improvement  of  mental  state,  diminution  in 
violence  of  choreo-athetotic  movements. 

The  important  findings  on  neurological  examination 


STUDIES  OF  SELECTED  CASES        229 

were:  choreo-athetotic  movements  of  the  left  side,  most 
marked  in  the  head,  face  and  arm,  normal  reflexes  on 
the  left,  increased  reflexes  on  the  right,  with  a  positive 
Babinski  and  ankle  clonus;  bilateral  ptosis  most  marked 
on  the  left,  slight  weakness  of  the  lower  portion  of  the 
face  on  the  right,  conjugate  deviation  of  the  eyes  to  the 
left,  nystagmus  to  the  left,  slight  diminution  in  ocular 
movements  to  the  right,  pupils  which  reacted  sluggishly 
to  light  and  on  accommodation,  probablj-  a  left  homony- 
mous hemianopsia,  ataxia  of  the  left  arm  and  leg. 

In  consideration  of  the  history  of  prolonged  somno- 
lence, lethargy  and  transient  cranial  nerve  palsies, 
together  with  the  spinal  fluid  findings,  the  clinical  con- 
dition seems  to  be  quite  clearly  epidemic  encephalitis. 
The  neurological  findings  cannot  be  explained  on  the 
basis  of  a  single  lesion,  but  the  predominating  signs  seem 
to  conform  closelj^  enough  to  the  thalamic  syndrome  to 
allow  of  a  diagnosis  of  a  lesion  of  the  right  optic  thalamus. 

The  accepted  signs  of  a  thalamic  lesion  are  unilateral 
pain,  anaesthesia  (deep,  and  frequentl}^  superficial), 
ataxia,  astereognosis,  choreo-athetoid  movements.  Other 
findings  from  involvement  of  neighboring  structures 
include  hemiplegia,  hemianopsia,  disturbances  of  ocular 
movements  and  of  the  pupillary  reflexes. 

In  this  patient  dysaesthesia  and  pain  were  present. 
Hemianaesthesia  was  not  present,  at  least  during  his 
stay  in  the  hospital,  there  being  a  moderate  hyperaes- 
thesia  to  touch  over  the  left  forearm  and  hand  and  pain 
on  pressure  over  the  left  forearm  and  calf.  There  was  no 
astereognosis,  the  patient  recognizing  the  size,  shape, 
consistence  and  surface  characteristics  of  objects  placed 
in  either  hand.  He  was  also  able  to  reproduce  with  his 
right  hand  smy  position  in  which  his  left  hand  and  fingers 
were  placed.  Ataxia  and  choreo-athetoid  movements  were 


230  EPIDEMIC    ENCEPHALITIS 

present.  There  were  disturbances  of  the  ocular  move- 
ments and  pupillary  reactions,  and  before  he  entered  the 
hospital  weakness  of  the  left  leg  and  a  left  homonymous 
hemianopsia.  The  increased  deep  reflexes  and  Babinski 
on  the  right  side  must  of  course  be  due  to  a  separate 
lesion  in  the  corresponding  pyramidal  tract. 


CHAPTER  XXVII 


CASE    REPORT  XI 


Mr.  A.  AI.     Aged  fifty.     Married.     Iron-inolder. 

Admitted  to  the  hospital  March  6,  1920. 

ChieJ  Complaints.  Drowsiness,  fever,  twitchings  of 
the  muscles  of  the  abdomen  and  legs;  duration  two  weeks. 

Personal  History.  Patient  has  always  been  strong 
and  healthy;  does  not  remember  any  of  the  diseases  of 
childhood.  He  is  not  subject  to  respiratory  infections, 
and  has  had  no  nervous  disorders  of  any  kind. 

Present  Illness.  The  onset  was  two  weeks  before  ad- 
mission at  which  time  he  had  a  bad  cold  in  the  head  and 
fever.  This  was  so  severe  that  he  stopped  work  and  went 
to  bed.  There  was  some  aching  in  his  head,  back  and 
legs.  He  was  examined  by  a  physician  who  told  him  that 
he  had  influenza.  Three  days  after  the  onset  he  noted  a 
twitching  of  the  muscles  of  the  left  leg;  within  a  few 
hours  the  right  leg,  the  right  arm  and  then  the  muscles 
of  the  entire  body  were  involved.  The  twitching  was 
likened  to  short  electrical  shocks  occurring  in  all  portions 
of  his  body  involving  his  face  and  tongue  as  well  as  the 
muscles  of  the  trunk  and  extremities,  so  that  it  was  prac- 
tically impossible  for  him  to  talk  or  to  swallow.  Attempts 
to  hold  his  arms  or  legs  rigidly,  if  resulting  in  any  effort, 
possibly  increased  the  severity  of  the  contractions.  This 
generalized  twitching  lasted  about  three  days  and  then 
stopped  to  a  large  extent  in  the  face,  upper  extremities, 
upper  portion  of  the  trunk  and  back.  The  twitching  in 
the  abdominal  muscles  and  in  the  lower  limbs,  however, 

231 


232  EPIDEMIC    ENCEPHALITIS 

has  continued  with  the  same  intensity  up  to  the  present 
time.  There  have  also  been  fever,  sweating,  dryness  of 
the  membranes  of  the  nose  and  throat,  anorexia,  labored 
stammering  speech,  difficulty  in  swallowing  and  in  urina- 
tion. There  were  no  paralyses  of  the  extremities,  although 
his  limbs  felt  weak  and  trembly  and  he  was  unable  to 
walk.  His  family  noticed  that  his  eyes  watered  and  his 
eyelids  drooped.  At  present  he  has  no  pain;  he  feels 
drowsy  and  tired,  but  is  not  disturbed  by  the  muscular 
contractions  in  the  abdomen  and  legs. 

PHYSICAL    EXAMINATION 

General  appearance  is  that  of  a  middle-aged  man, 
acutely  ill,  flushed  and  sweating.  There  are  sudden, 
jerky,  spasmodic,  twitching  movements  most  marked 
in  the  abdominal  muscles  and,  to  a  less  extent,  in  the 
lower  limbs.  The  skin  is  flushed  and  moist.  Over  the 
sternum  there  are  a  few  very  small  red  spots  which  re- 
semble petechiae. 

Head.     No  deformity  or  sinus  tenderness. 

Eyes.  The  lids  blink  frequently  and  are  held  partially 
closed.  There  is  slight  double  ptosis;  the  upper  lids  cannot 
be  elevated  enough  to  expose  the  sclera  above  the  iris. 
The  small  blood  vessles  of  the  conjunctiva  are  injected. 
Eyegrounds:  The  discs  are  normal,  sharply  outlined, 
the  vessels  slightly  tortuous.  There  are  no  hemorrhages. 

Nose.     No  evident  discharge  or  signs  of  inflammation. 

Ears.  No  mastoid  tenderness.  The  right  drum  is 
distinctly  thickened  along  the  site  of  the  malleus,  almost 
obscuring  that  bone.  There  is  no  redness  or  bulging. 
In  the  left  drum  the  landmarks  are  visible.  There  is  some 
redness  in  Shrapnell's  membrane. 

Mouth.  There  is  a  slight  tremor  of  the  tongue  and 
lips.  The  teeth  are  dirty.  One  lower  right  molar  is  carious. 


STUDIES  OF  SELECTED  CASES        233 

There  is  a  peculiar  mottled  erosion  of  the  roof  of  the 
mouth  on  the  right  side  which  is  covered  with  a  slight 
whitish  exudate.  The  soft  palate  is  symmetrical  and 
moves  with  swallowing.  The  left  tonsil  is  larger  than  the 
right;  both  appear  reddened. 

Neck.  No  rigidity.  The  thyroid  is  not  palpable.  No 
abnormal  pulsations. 

Heart.  Outline  normal.  Apex  not  palpable,  action  regu- 
lar. The  sounds  are  of  normal  character  at  the  apex  and 
base;  no  murmurs.  Pulse  96.  Blood  pressure  lGO-90. 

Lungs  are  clear  and  resonant  throughout.  Respiration 
is  jerky  due  to  the  contractions  of  the  abdominal  muscles. 

Abdomen  is  soft.  There  is  a  full,  rounded  mass  above 
the  symphysis  pubis  which  seems  to  be  a  distended  blad- 
der. The  liver  and  spleen  are  not  felt  or  enlarged  to 
percussion.  No  rose  spots. 

Extremities.  There  is  no  deformity  or  edema;  no 
spasticity  or  tendency  to  catatonia. 

Superficial  Lymph  Nodes  are  nowhere  enlarged. 

Rectal  Examination.     No  hemorrhoids. 

Prostate  is  small;  no  masses. 

Temperature  on  admission  to  the  hospital  was  103.2. 
Respirations  22. 

NEUROLOGICAL  EXAMINATION:  MARCH  16,  1920 

Voluntary  Motor  System.  Abnormal  Attitudes  and 
Deformities.  The  patient  is  lying  on  his  left  side  in  bed 
with  eyes  closed,  apparently  asleep.  His  face  and  fore- 
head are  moist  with  perspiration  and  he  has  an  expression- 
less appearance  which  is  not  unlike  that  seen  in  typhoid 
fever.  The  mouth  is  closed  and  respiration  is  not  labored. 
Color  is  good  and  there  is  neither  cyanosis  nor  jaundice. 
He  is  easily  aroused  and  when  so  is  alert,  talking  easily 


234 


EPIDEMIC    ENCEPHALITIS 


and  without  hesitation,  being  perfectly  rational.  There 
is  a  slight  lateral  movement  of  the  trunk  due  to  the 
spasmodic  contraction  of  the  abdominal  muscles. 

Gait.     Not  tested. 

Coordination.  Equilibratory  not  tested.  Non-equi- 
libratory:  Finger-to-nose,  pointing  and  past-pointing  tests 
of  the  upper  extremities  show  normal  precision  of  move- 
ment. Heel-to-knee  tests  are  not  performed  so  well,  the 
heel  on  each  side  being  placed  above  the  opposite  knee, 
and  moved  downward  along  the  skin  in  a  rather  jerky, 
irregular  manner.  There  is  no  dysmetria  or  adiadochoki- 
nesis. 

•  Skilled  Acts.  The  voice  is  weak,  the  speech  stammer- 
ing, though  the  patient  states  that  it  has  improved  much 
since  the  onset  when  he  was  practically  unable  to  speak 
intelligibly.  There  is  no  dyspraxia. 

Reflexes: 

Deep  Right  Left 

Jaw 2  2 

Pectoral.. 2  2 

Biceps 2  2 

Triceps 1  1 

Radial 2  2 

Ulnar 1  1 

Wrist 1  1 

Suprapatellar 0  0 

Patellar 2  2 

Achilles 2  2 

Periosteal  uncrossed Absent  Absentj 

"-  Superficial 

Supra-umbilical Absent  Absent 

Suprapubic Absent  Absent 

Upper  lateral  abdominal Absent  Absent 

Lower  lateral  abdominal Absent  Absent 

Cremasteric Present  Present 

Plantar  flexion Absent  Absent 

Babinski  and  modifications Absent  Absent 


STUDIES  OF  SELECTED  CASES 


235 


Abnormal  Involuntary  Movements.  There  are  repeated 
sudden  clonic  contractions  of  the  abdominal  muscles 
which  are  at  times  rhythmical  and  alternating,  occurring 
first  on  one  side  of  the  abdomen  and  then  on  the  other. 
On  the  right  side  the  umbilicus  is  moved  outward  as 
though  the  contraction  were  of  the  transversalis,  while 
on  the  left  side  it  is  elevated  and  moved  outward  as 
though  due  to  contraction  of  the  external  oblique.  The 
contractions  are  separated  by  varying  intervals  and  are 


>^^:mL^mBm 


Fig.  .'54.— Case  XI. 


General   Appeaiaiue. 
Lethargy. 


Constant    State  of 


not  continuous.  When  occurring  most  rapidly  there  are 
about  30  to  the  minute.  Similar  twitchings  are  also 
present  in  the  muscles  of  the  leg,  though  they  are  more 
irregular  and  seem  to  involve  a  greater  number  of  muscles. 
At  times  slight  twitchings  are  seen  in  the  muscles  of  the 
arms  and  also  the  face  especially  involving  the  muscles 
in  the  neighborhood  of  the  mouth.  These  are  of  much 
less  frequent  occurrence  than  those  in  the  legs  and 
abdomen.   Not  more  than  a  single  muscle  is  affected 


236 


EPIDEMIC    ENCEPHALITIS 


Fig.  55. — Case    XI.     Shaded    Area — Hypsesthesia,    Hypaljj;esia 
Thermohypesthesia. 


STUDIES  OF  SELECTED  CASES        237 

by  each  contraction,  and  at  times  it  is  apparently  limited 
to  a  portion  of  one  muscle.  Active  movements  and 
efforts  to  control  the  twitching  are  said  by  the  patient 
to  make  it  worse,  but  on  his  attempting  to  sit  up,  con- 
traction of  the  abdominal  muscles  seems  to  inhibit  the 
twitching.  There  are  no  tremors,  choreiform  or  athetoid 
movements. 

Muscle  Strength.  The  patient  is  able  to  rise  from  the 
recumbent  to  the  sitting  position.  No  attempt  was 
made  to  make  him  get  out  of  bed.  Opposed  and  un- 
opposed movements  of  the  neck,  upper  extremities 
and  trunk  do  not  show  any  special  weakness.  It  is  diffi- 
cult for  him  to  hold  either  lower  limb  above  the  bed 
for  any  length  of  time.  He  has  a  subjective  sense  of 
weakness  in  both  legs  and  there  seems  to  be  a  general 
diminution  in  strength  which  is  not  more  marked  on  one 
side  than  on  the  other  and  does  not  involve  any  particular 
muscle  group. 

Muscle  Status.  The  volume  and  contour  are  normal. 
The  muscles  are  soft  and  of  normal  tone.  There  is  a  slight 
increased  irritability,  light  percussion  causing  contrac- 
tion of  a  few  muscle  fibers  in  almost  any  of  the  larger 
muscles  of  the  trunk  or  extremities.  Myoidema  is 
present  in  both  deltoids. 

Abnormal  Associated  Movements.     No  observation. 

Nerve  Status.  Irritability:  Trousseau's  sign  negative; 
Chvostek's  sign  negative. 

General  Sensory.  Sense  of  touch  is  diminished  over 
both  legs  and  lower  abdomen  and  back.  Cotton  is  per- 
ceived everywhere  but  there  is  a  good  deal  of  uncertainty 
about  it  on  both  legs  below  the  knee.  Localization  below 
the  knee  is  very  difficult  and  discrimination  between 
sharp  and  dull  over  both  limbs  is  uncertain.  There  is 
hypaesthesia  over  this  area  and  difficulty  in  discriminat- 


238  EPIDEMIC    ENCEPHALITIS 

ing  between  cool  and  warm  temperatures.  Vibratory, 
pressure,  muscle  tendon  sense  and  stereognostic  percep- 
tion are  normal. 

Cranial  Nerves  and  Head.  Olfactory  Nerve  and 
Nose.     The  odor  of  menthol  is  perceived  in  each  nostril. 

Optic  and  Oculomotor  Apparatus.  Visual  acuity  is  not 
accurately  tested,  but  the  patient  states  that  he  cannot 
see  quite  so  clearly  as  before  the  illness  commenced. 
Perimetry,  roughl}^  tested,  is  normal.  The  pupils  are  of 
medium  size,  equal,  regular,  reacting  actively  to  light 
and  on  accommodation.  The  palpebral  fissures  each 
measure  7  millimeters.  There  is  no  exophthalmos  or 
enophthalmos.  There  is  partial  bilateral  ptosis,  he  is 
unable  to  uncover  more  than  half  of  the  iris  above  the 
pupil.  There  is  no  strabismus  or  other  ocular  deviation. 
The  conjugated  eye  movements  are  normal.  Nystagmus 
is  absent. 

Acoustic  Nerve  and  Ear.  A  watch  is  heard  three 
inches  from  the  right  ear  and  eighteen  inches  from  the 
left.  Bone  conduction  is  greater  than  air  on  the  right  side, 
and  normal  on  the  left. 

Trigeminus  Nerve  and  Mouth.  Voluntary  movement 
of  the  jaw  is  normal  in  all  directions.  Corneal  sensibility 
is  practically  absent  on  the  right  side  and  diminished  on 
the  left. 

Facial  Nerve  and  Face.  Movements  of  both  sides  oj 
the  face  are  equal  and  symmetrical,  but  there  is  a 
smoothed-out  appearance  of  the  lower  face  and  an 
inflexibility  of  the  oral  musculature  so  that  there  is  no 
free  play  of  emotional  expression. 

Glossopharyngeus  and  Vagus  Nerves,  Pharynx  and 
Larynx.  The  uvula  is  in  the  midline.  The  palatal  re- 
flexes and  pharyngeal  reflex  are  present.  Swallowing, 
respiratory  and  cardiac  action  are  normal. 


STUDIES  OF  SELECTED  CASES        239 

Spinal  Accessory  Nerve.  Both  sternomastoid  and 
trapezius  musclos  contract  normally. 

Hypoglossus  Nerve  and  Tongue.  The  position  of  the 
tongue  when  protruded  is  median  and  its  movements  in 
all  directions  are  normal.  There  is  a  slifi;ht  fine  tremor  of 
the  tongue,  but  no  evident  fibrillary  contraction. 

Tegumentary.  There  is  very  little  hair  on  the  chest, 
arms  or  legs,  and  the  arrangement  of  the  pubic  hair  is  of 
the  female  type.  Over  the  sacrum  there  are  two  or  three 
small  superficial  decubital  ulcers. 

Summary  of  Neurological  Examination.  The  impor- 
tant findings  on  neurological  examination  are: 

1.  Lethargic  state  from  which  he  is  easily  aroused, 

2.  Dysarthria  and  lower  facial  rigidity. 

3.  General  weakness  of  the  lower  extremities. 

4.  Diminution  of  tactile,  pain  and  temperature  sense, 
with  poor  localization  and  discrimination  over  both  legs 
and  lower  abdomen. 

5.  Sudden  clonic  contractions  in  muscles  of  the  ab- 
domen and  legs,  and,  rarely,  of  arms  and  face. 

LABORATORY    EXAMINATIONS    AND    CLINICAL    NOTES  • 

Blood  Wassermann,  March  6,  1920. 

Alcohol  antigen Negative 

Cholesterin  antigen Negative 

Blood  Culture,  March  6,  1920. 

A  long  bacillus;  probably  a  contamination. 

Spinal  Puncture,  March  6,  1920. 

Amount 15  c.c. 

Pressure Normal 

Appearance Clear  and  colorless 

Cells 14  lymphocytes 

Globulin Negative 


240  EPIDEMIC    ENCEPHALITIS 

Wassermann  2c. c.  Ic.c.    6c. c.    2c.c. 

Alcohol  antigen Neg.  Neg.  Neg.  Neg. 

Cholesterin  antigen  .  .  .  Neg.  Neg.  Neg.  Neg. 
Colloidal  gold  curve  1,  Ihz,  2,  2,  U^,  0,  0,  0,  0,  0. 
Culture Sterile 

Throat  Culture,  March  7,  1920. 

No  Klebs  Loeffler  bacilli. 

Blood  Count,  March  7,  1920. 

White  blood  cells 18,140 

Polymorphonuclear  leucocytes 79% 

Lymphocytes 19  % 

Transitionals 2  % 

Blood  Culture,  March  8,  1920. 

Sterile. 

Urine  Examination,  March  8,  1920. 

Specificgravity 1 .  032 

Reaction Acid 

Color Dark  amber 

Sediment Slight  flocculent 

precipitate 

Albumin Trace 

Ghicose Absent 

Microscopical  examination A    few  hyaline 

easts;  no  white 
blood  cells. 

Mouth  Culture,  March  9,  1920. 

Hemolytic      staphylococcus     aureus     and     streptococcus 

predominate. 
Organisms  of  Vincent's  angina  present  in  smears. 

Blood  Urea,  March  10,  1920. 

.54  grams  per  litre. 

Phenolsulphonephthalein  test,  64  per  cent  excreted  in 
two  hours. 


STUDIES  OF  SELECTED  CASES        241 

Spinal  Puncture,  March  11,  1920. 

Amount lo  c.c. 

Pressure Slighth-  increased 

Appearance Clear  with  slightly 

pinkish  tinge 

Cells 5  lymphocytes 

Globuhn ? 

X-ray  Examination  of  Teeth  and  Si7iuses,  IMarch  10, 
1920. 

Left  frontal  absent.  Remaining  right  lower  molar  distinctly 
carious.  Xo  evidence  of  abscesses  in  any  of  the  teeth.  No  sign 
of  disease  in  accessory  sinuses. 

Blood  Uric  Acid:  March  12,  1920. 

3.5  mg.  per  100  c.c. 

Spinal  Puncture,  March  29,  1920. 

Amount 15  c.c. 

Pressure Not  increased 

Appearance Clear,  colorless 

Cells 20  lymphocj-tes 

Globulin + 

March  24,  1920.  During  the  first  week  in  the  hospital 
the  fever  continued  about  101°.  In  the  second  week  it  was 
about  a  degree  lower.  During  the  past  week  it  has  taken 
a  slightly  upward  trend  and  to-day  reached  101.4°.  With 
the  increase  in  fever  the  lethargj^  has  become  more 
marked,  so  that  it  is  now  not  so  easy  to  arouse  him,  and 
unless  actively  disturbed  he  is  continuously  in  a  stupor. 
Speech  is  possiblj^  a  little  less  difficult.  Sensory  changes 
and  weakness  of  the  leg  remain  unaltered.  The  bed-sores 
on  the  back  are  healing.  On  admission  there  was  urinary 
retention,  later  the  urine  was  passed  involuntarily,  but 
to-day  hevoided  voluntarily  when  aroused.  The  muscular 
twitchings  have  remained  unchanged  during  the  period 
of  observation. 

March  29,  1920.     Fatal  termination. 

16 


242  EPIDEMIC    ENCEPHALITIS 

AUTOPSY  March  30,  1920.     10  hrs.  p.  m. 
By  Dr.  H.  E.  Meleney 

The  body  is  that  of  a  well  developed,  somewhat  em- 
aciated middle-aged  white  man  measuring  174  cm.  and 
weighing  150  lbs.  There  is  considerable  rigor  mortis  and 
moderate  lividity  of  the  dependent  parts.  No  skin  erup- 
tions. There  are  two  bed  sores  over  the  sacrum.  The  hair 
on  the  scalp  is  profuse  and  elsewhere  is  of  normal  dis- 
tribution. The  eyes  are  sunken  and  eye  balls  rather  soft. 
The  pupils  are  unequal,  the  left  measuring  4  mm.  and 
the  right  5  mm.  They  are  both  circular.  Conjunctivae  pale; 
no  petechise.  Ears  and  nose  are  externally  negative. 
Mouth  contains  small  amount  of  bloody  mucus  and 
there  is  blood  on  the  face  which  has  apparently  run  out 
of  the  mouth.  Teeth  are  dirty,  there  is  a  slight  amount  of 
pyorrhea  but  very  little  caries.  Right  lower  molar  has 
an  abscess  on  its  front  aspect.  Superficial  lymph  nodes 
not  enlarged.  Right  testicle  is  smaller  and  softer  than 
the  left.  No  edema. 

Abdominal  Cavity.  Panniculus  measures  2.5  cm. 
Fat  is  normal  in  appearance.  There  is  extensive  black 
discoloration  of  the  parietal  peritoneum  beneath  the 
rectus  muscle  on  both  sides  and  above  this  is  a  slight 
hemorrhage  into  the  subperitoneal  tissue.  This  hemor- 
rhage does  not  extend  into  the  muscle  but  the  muscle  is 
slightly  pale.  The  cavity  contains  no  free  fluid.  Perito- 
neum is  everywhere  smooth  and  glistening.  The  liver  ex- 
tends just  to  the  costal  margin.  The  spleen  is  surrounded 
by  a  few  firm  adhesions  to  the  omentum  and  diaphragm 
and  is  high  up  under  the  costal  margin.  The  bladder  is 
contracted.  Appendix  is  retro-cecal  about  6  cm.  in 
length;  its  distal  half  pale  and  fibrous  and  bound  by 
rather  firm  adhesions  to  the  mesentery  of  the  ascending 


STUDIES  OF  SELECTED  CASES        243 

colon.  There  is  much  mesenteric  fat.  Diaphragm  on 
right  side  is  at  the  level  of  the  fourth  interspace  and  on 
the  left  side  at  the  level  of  the  fifth  rib. 

Thoracic  cavity.  The  left  lung  is  not  adherent ;  no 
free  fluid  in  the  cavity.  Right  lung  bound  down  laterally 
and  posteriorly  by  firm  fibrous  adhesions;  no  fluid  in 
cavit3^  Pericardial  cavity  contains  about  25  cc.  of  clear, 
straw-colored  fluid.  No  evidence  of  percarditis. 

Heart.  Weighs  300  gms.  It  is  very  flabb}'  and  there  is 
rather  an  extensive  amount  of  epicardial  fat.  Epicardium 
itself  is  normal.  The  coronary  arteries  are  not  tortuous. 
The  right  auricle  on  its  outer  surface  shows  one  small 
fibrous  patch.  Internally  it  is  normal.  The  tricuspid  orifice 
admits  the  tips  of  four  fingers.  The  cavities  are  all  of 
normal  size.  The  mitral  valve  shows  distinct  thickening 
at  its  line  of  closure,  particularly  the  anterior  flap.  The 
posterior  papillary  muscle  shows  some  fibrosis  and  some 
splotches  which  appear  like  hemorrhages  into  the  tissue. 
The  endocardium  of  the  left  ventricle  is  slighth'  thick- 
ened in  irregular  streaks.  The  aortic  valve  shows  marked 
thickening  of  all  cusps  with  partial  calcification.  There 
are  yellow  plaques  in  the  endocardium  just  below  the 
valve  and  in  the  sinuses  of  Valsalva  and  in  the  beginning 
of  the  aorta.  The  coronary  arteries  show  a  few  raised 
yellow  plaques  in  the  first  few  centimeters  which  narrow 
the  Imiien,  but  beyond  these  the  arteries  arc  delicate. 
The  mj'ocardium  is  everywhere  pale  and  very  flabby 
but  shows  no  fibrosis  and  no  gross  fatty  changes. 

Measurements 

Tricuspid  valve  13  cm. 

Mitral  valve  9.5  cm. 

Pulmonary  valve  7.2  cm. 

Aortic  valve  8  cm. 

Left  ventricle  14  mm. 


244  EPIDEMIC    ENCEPHALITIS 

Right  ventricle  4  mm. 

Aorta  has  a  few  fiat  yellow  plaques  throughout  its 
course  and  in  the  arch  two  raised  white  plaques  in  which 
the  intima  is  greatly  thickened  over  a  thick  fatty  plaque 
between  it  and  the  media.  It  is  normally  elastic. 

Lejt  lung  weighs  560  gms.  It  does  not  collapse  but 
crepitates  throughout  most  of  its  surface.  It  is  reddish- 
blue  with  much  anthracosis.  On  the  lateral  aspect  of  the 
lower  lobe  is  a  stony  hard  nodule  about  1.5  cm.  in  diame- 
ter, part  of  the  surface  of  which  is  white  in  color.  On  sec- 
tion the  entire  lung  is  greatly  congested  exuding  a  large 
amount  of  bloody  frothy  fluid.  It  is  apparentl^^  quite 
edematous  and  emphysematous.  Lower  lobe  has  a  few 
very  small  peribronchial  firm  areas  which  apparently 
are  lobular  consolidations.  Bronchi  are  moderately  con- 
gested and  contain  considerable  frothy,  bloody  fluid. 
Pulmonary  artery  contains  a  few  flat  yellow  plaques. 
The  bronchial  h-mph  nodes  are  slighth'  enlarged,  black 
and  rather  firm. 

Right  lung  weighs  590  gms.  It  does  not  collapse  except 
on  anterior  border.  On  the  anterior  surface  over  the 
upper  lobe  extending  slightly  into  the  middle  lobe  are 
very  firm  fibrous  tags  enclosing  fat.  The  lung  is  very 
anthrocotic  on  the  surface,  otherwise  has  a  reddish-blue 
color.  All  lobes  are  firmly  adherent  b}^  fibrous  tissue.  On 
section  the  lung  is  air-containing,  edematous  and  appar- 
ently emphysematous,  the  surface  exuding  abundant 
bloodj^  froth}'  fluid.  The  lower  lobe  is  fii-mer  than  the 
upper.  It  shows  moderate  congestion  but  has  no  definite 
areas  of  consolidation.  There  are  no  scars  in  the  lung 
tissue  beneath  the  adhesions  described  above.  The 
bronchial  lymph  nodes  at  the  hilus  are  similar  to  those 
of  the  left  lung. 

Liver.     Weighs  1360  gms.  The  upper  surface  is  red- 


STUDIES  OF  SELECTED  CASES        245 

dish-brown,  the  lower  surface  partly  stained  blue  by 
contact  with  the  intestines.  On  section  it  is  brown.  There 
is  slight  evidence  of  congestion  at  the  center  of  the 
lobules  and  slight  fat  infiltration  at  the  periphery.  The 
lobulations  are  not  very  distinct.  The  organ  is  quite 
flabby  and  friable.  The  gall-bladder  projects  about  3  cm. 
beyond  the  border  of  the  liver.  It  contains  light  brown 
mucoid  bile  with  a  few  yellow  flakes.  The  ducts  are  patent. 

Spleeyi  weighs  110  gms.  Its  entire  diaphragmatic  sur- 
face is  adherent  to  diaphragm  by  firm  fibrous  adhesions. 
The  remainder  of  the  surface  is  discolored  blue  where  it 
was  in  contact  with  the  colon.  It  is  flabby;  capsule 
wrinkled  and  slightly  thickened.  On  section  it  is  blotchy 
red-blue  in  color.  Trabeculae  appear  to  be  increased. 
Splenic  corpuscles  scarcel}^  visible.  The  tissue  is  flabby 
and  friable. 

Suprarenals.  Equal  in  size,  small  and  flat.  They  con- 
tain considerable  fat  in  the  cortex  with  a  rather  broad 
inner  zone  and  a  small  amount  of  white  medulla. 

Kidneys  together  weigh  230  gms.  Right  organ  is 
flabby.  Capsule  strips  easily  leaving  a  smooth  surface 
with  distinct  stellate  veins.  The  kidneys  are  equal  in 
size.  Surface  is  smooth.  Anterior  surface  is  congested. 
The  glomeruli  stand  out  as  red  spots.  The  striations 
are  distinct.  Medulla  appears  normal.  Pelvis  and  ureter 
are  normal.  Left  kidney  is  more  congested  than  the 
right. 

Bladder.  It  is  collapsed  but  not  contracted  and  con- 
tains a  small  amount  of  bloody  urine.  The  mucosa  shows 
areas  of  extreme  submucous  hemorrhage  and  occasional 
shallow  erosions  in  the  mucosa. 

Prostate.     Grossly  normal. 

Testicles.  Left  is  soft  and  congested.  Has  faint  brown 
tinge.   Tubules  string  out.   Right  is  slightly  adherent 


246  EPIDEMIC    ENCEPHALITIS 

around  epididymis  to  parietal  layer  of  tunica.  It  is 
softer  and  somewhat  smaller  than  the  left.  The  sac  of  the 
tunica  vaginalis  contains  a  small  calcified  mass  of  ma- 
terial free  in  the  cavity. 

Pancreas.     Is  congested  but  otherwise  grossly  normal. 

Gastrointestinal  Tract.  Stomach  shows  congestion  of 
the  mucosa.  The  organ  contains  about  200  cc.  of  brownish 
fluid  containing  many  cofTee-ground  particles.  The  duo- 
denum is  normal.  The  beginning  of  the  jejunum  shows 
extreme  congestion.  The  rest  of  the  small  intestine  is 
essentially  normal.  The  mucosa  of  the  appendix  shows 
considerable  erosion  and  contains  light  yellow  material 
which  maj^  be  pus,  but  its  wall  is  not  congested.  Colon 
is  normal. 

Organs  of  Mouth  and  Neck.  The  anterior  portion  of 
the  tongue  is  covered  with  patches  of  thick  yellow  fur. 
There  is  considerable  hypertrophj^  of  the  lymphoid 
tissue  at  the  base  of  the  tongue.  Tonsils  are  rather  large 
but  not  inflamed.  Pharynx  is  normal.  Oesophagus  shows 
erosion  of  its  mucosa  throughout  its  entire  length  except 
upper  7  cm.,  apparently  postmortem  digestion  from 
vomited  material.  Larynx  is  normal.  Trachea  is  very 
slightl}^  congested,  the  congestion  increases  until  it  be- 
comes extreme  in  the  large  bronchi.  The  thyroid  is  small, 
rather  soft  and  symmetrical.  It  appears  grossly  normal. 

Head.  The  calvarium  is  normal  except  for  a  thinning 
at  a  point  over  about  the  middle  of  the  right  parietal 
lobe  beneath  which  the  dura  is  thin  and  the  pia  is  thick 
and  contracted  and  there  is  some  atrophy  of  the  con- 
volutions. At  a  corresponding  point  on  the  left  side  is 
similar  congestion  except  less  marked.  The  pia  and 
arachnoid  of  the  whole  brain  are  slightly  thickened  and 
hazy.  There  is  no  excess  of  spinal  fluid  and  the  brain  is 
not  congested.   No  gross  lesions  are  found  in  partial 


STUDIES  OF  SELECTED  CASES        247 

sectioning.  Part  of  the  brain  is  hardened  without  sec- 
tioning. The  sinuses  of  the  skull  and  middle  ears  are 
normal. 

Spinal  cord  appears  somewhat  smaller  in  diameter 
than  normal  in  the  thoracic  and  lumbar  regions.  There 
is  no  gro.ss  thickening  of  the  meninges.  In  the  thoracic 
and  lumbar  regions  it  is  softer  than  higher  up,  particu- 
larly in  the  region  of  the  posterior  columns.  There  is  no 
congestion  or  hemorrhage.  No  gross  lesions  of  posterior 
spinal  ganglia. 

Note.  The  termination  occurred  as  this  report  was 
going  to  press  and  there  was  not  sufficient  time  for  the 
microscopic  examination  of  the  tissue. 

SUMMARY 

The  history  at  onset  was  of  an  upper  respiratory  in- 
fection with  fever  and  its  attendant  symptoms.  Three 
days  later  there  developed  sudden  spontaneous  con- 
tractions in  isolated  muscles  throughout  the  whole  body. 
The  entire  voluntary  musculature,  including  that  of  the 
tongue  and  throat,  seemed  to  be  involved,  with  the  sole 
exception  of  the  muscles  of  the  eyes.  This  continued  for 
three  days  and  then  largely  disappeared  from  the  head, 
arms  and  upper  trunk  but  continued  in  the  limbs. 
Speech  remained  difficult  and  stammering.  Soon  weak- 
ness and  sensory  disturbances  in  the  lower  limbs  de- 
veloped; also  difficulty  in  urination,  bilateral  ptosis  and 
the  characteristic  stupor  of  epidemic  encephalitis.  There 
was,  therefore,  clinical  evidence  of  wide-spread  lesions 
involving  the  brain  stem  and  spinal  cord.  For  a  week 
prior  to  death  the  stupor  gradually  increased.  The 
temperature  rose  steadily  until  it  reached  104  degrees. 
The  pulse  rate  continued  to  advance  until  the  day  of 
termination  when  it  ranged  between  120  and  140. 


CHAPTER  XXVIII 


CONCLUSIONS 


Epidemic  encephalitis  is  a  disease  whose  virus  has  a 
special  affinity  for  the  central  nervous  system.  It  is  prob- 
able that  the  disease  is  similar  to  anterior  poliomyelitis 
in  being  a  general  infection,  with  its  main  localization 
in  the  neuraxis. 

The  clinical  picture  varies  greatly,  but  includes  both 
general  and  localizing  signs.  The  portion  of  the  nervous 
system  most  frequently  involved  is  the  peri-aqueductal 
region  of  the  midbrain.  No  portion  of  the  nervous  system 
seems  immune,  but  the  action  of  the  virus  on  the  motor 
elements  is  most  severe.  The  more  primitive  and  phylo- 
genetically  older  portions  of  the  motor  system  are  more 
often  affected  than  the  later  developed  pyramidal  system. 

An  extensive  observation  of  epidemic  encephalitis 
warrants  the  classification  of  the  cases  into  certain  more 
or  less  well  defined  clinical  groups.  Of  these  the  most 
frequently  encountered  are  the  following: 

1.  The  lethargic  type 

2.  The  cataleptic  type 

3.  The  hemiplegic  type 

4.  The  paralysis  agitans  type 

5.  The  polioencephalitic  type 

6.  The  choreiform  type 

7.  The  myoclonic  type 

8.  The  multiform  type. 
Other  less  common  forms  are: 

9.  The  meningitic  type 

248 


STUDIES    OF    SELECTED    CASES  249 

10.  The  acute  anterior  poliomyelitic  type 

1 1 .  The  epilepto-maniacal  type 

12.  The  acute  psychotic  type 

13.  The  sympathetic  system  type 

14.  The  abortive  type. 

There  are  a  considerable  number  of  cases  showing  wide- 
spread involvement  of  the  nervous  system  without 
prominent  localizing  symptoms.  Some  method  of  classifi- 
cation, however,  is  valuable  as  an  aid  in  the  discussion 
of  the  many  different  forms  in  which  the  manifestations 
of  this  disease  may  appear. 

Concerning  the  pathogenesis  of  epidemic  encephalitis, 
as  its  initial  symptoms  are  frequent h"  those  of  an  upper 
respiratory  infection,  it  is  possible  that  the  portal  of 
entr}?-  of  the  virus  is  by  way  of  the  naso-pharyngeal 
mucous  membrane.  Whether  this  is  the  most  frequent 
or  the  only  situation  where  the  virus  gains  entrance  to 
the  body,  or  whether  the  inflammation  is  due  to  a  sec- 
ondary invasion  of  this  membrane,  is  not  at  all  clear. 
The  method  of  conduction  of  the  infecting  agent  to  the 
nervous  system  and  the  channels  by  which  the  infection 
spreads  within  the  central  nervous  system,  are  not  known. 
The  similarity  of  the  pathological  changes  to  Heine- 
Medin's  disease  and  to  Borne's  disease  leads  one  to  sus- 
pect that  it  is  borne  by  the  lymphatics.  The  nature  of 
the  virus  is  unknown,  though  the  experimental  evidence 
advanced  thus  far  would  point  to  the  probability  of  its 
being  a  filterable  virus,  possibly  related  to  that  of  ante- 
rior poliomyelitis.  However,  there  is  very  little  evidence 
at  present  that  epidemic  encephalitis  can  be  produced  in 
monkeys  and  certainly  not  with  the  ease  and  reliability 
with  which  poliomyelitis  is  transmitted.  Von  Wiesner  of 
Vienna  was  the  first  to  report  the  results  of  experimental 
animal  inoculation.  His  monkey  subdurally  inoculated 


250  EPIDEMIC    ENCEPHALITIS 

with  human  nervous  tissue  died  in  48  hours  with  what 
proved  to  be  a  meningo-encephaUtis.  A  diplostrepto- 
coccus  was  isolated  from  the  lesion  and  was  at  first  sup- 
posed to  be  the  etiological  agent  of  epidemic  encephalitis; 
but  was  later  regarded  as  a  contamination.  Mcintosh 
reports  the  experimental  production  in  a  monkey  of  a 
disease  which  clinically  and  pathologically  resembled 
lethargic  encephalitis.  Loewe,  Hirshfeld  and  Strauss 
report  the  production  of  a  meningo-encephalitis  by  sub- 
dural inoculation  of  monkeys  and  rabbits  with  the  filtrates 
of  naso-pharyngeal  washings  and  naso-pharyngeal  mucous 
membrane  from  encephalitis  patients.  The  lesions  des- 
cribed have  apparentl}^  been  more  easily  produced  by  fil- 
trates of  naso-pharyngeal  membranes  and  of  nasal 
washings  than  by  inoculations  with  the  infected  nerve 
tissues  themselves.  The  animals  employed  were  mainl}^ 
rabbits.  That  extreme  caution  should  be  used  in  judging 
the  value  of  results  obtained  by  experimental  inoculation 
in  rabbits  has  been  noted  by  many  workers,  as  it  has 
been  shown  that  lesions  may  be  produced  in  this  animal 
when  any  foreign  material  is  injected.  Other  workers 
have  failed  to  corroborate  these  findings  with  similar 
inoculations. 

It  may  be  stated  without  reservation  that  our  knowl- 
edge of  the  pathogenesis  of  epidemic  encephalitis  leaves 
much  that  is  obscure. 

There  is  at  present  no  evidence  that  the  disease  is 
contagious,  and  no  light  has  been  thrown  on  the  method 
of  transmission.  The  therapeutic  measures  are  sympto- 
matic and  empyrical. 


BIBLIOGRAPHY 

1.  Abrahamson,  I.  A'.  York  M.  J..  Vol.  109,  S94,  1919. 

2.  Allen,  W.  C.  South.  M.  J.,  Vol.  XII,  231-235,  1919. 

3.  Barker,  L.  F.  Am.  J.  M.  Sc,  Vol.  CLIX,  No.  3,  337-353, 

March  1920. 

4.  Bassoe,  p.  J.  Am.  M.  Assn.,  Vol.  LXXII,  971,  1919. 

5.  Batten,  F.  E.  La7icet,  Lond.,  1918,  Vol.  1,  636. 

6.  Beall,  K.  H.  Texas  State  J.  M.,  XV,  129,  1919-20. 

7.  Belix,  H.  Bosto7i  M.  &  S.  J.,  CLXXX.  741,  1919. 

8.  Bergeron,  P.  X.  Arch.  Neurol.  &  Psychiat.,  1919,  II,  141-143. 

9.  Buzzard,  E.  F.  Lancet,  Lond.,  1918,  Vol.  I,  616.  Lancet,  Lond., 

1918,  Vol.  II,  835. 

10.  Climenko,  H.  at.  York  M.  J.,  CIX,  1919. 

11.  Crookshank,  F.  G.  Proc.  Roy.  Soc.  Med.,  Lond.,  Nov.  1918, 

XII,  Xo.  1,  Sect,  of  Med.,  pp.  i — xxiii. 

12.  Draper,  G.  Report  of  an  Inquirj^  into  an  Obscure  Disease, 

Encephalitis  Lethargica.  Report  of  the  Local  Government 
Board  on  Public  Health  and  Medical  Subjects.  New  Series, 
Xo.  121,  Lond.,  1918. 

13.  EcoNOMO,  Verein  f.  Psych,  u.  New.  in  Wieti,  April  17,  1917. 

Wien.  klin.  Wchnschr.  Vol.  XXX,  May  10,  1917.  Neurol. 
Centralbl.  Leipz.,  Vol.  XXXVI,  Nov.  1,  1917. 

14.  Ely,  F.  A.  J.  Am.  M.  Assn.,  LXXII,  985,  1919. 

15.  Flexner,  S.  J.  Ai7i.  M.  Ass7i.,  LXXIV,  865-869,  1920. 

16.  Gordon,  A.  N.  York  M.  J.,  Vol.  109,  837,  1919. 

17.  Hall,  A.  J.  Brit.  M.  J.,  Lond.,  No.  3017,  461,  Oct.  26,  1918. 

Lancet,  Lond.,  1918,  Vol.  I,  568. 

18.  House,  S.  J.  J.  A7n.  M.  Assn.,  LXXIV,  884-885,  1920. 

19.  Kennedy,  F.  Med.  Rec,  Vol.  95,  No.  16,  631,  1919. 

20.  Loewe,  L.,  Hirshfeld,  S.,  and  Strauss,  I.  J.  Infect.  Dis., 

Vol.  XXV,  No.  5,  378-383,  Nov.  1919. 

21.  LoNGUET,  P.  Semaine  Med.,  Par.,  12,  275,  1892. 

22.  Lowe,  F.  Guy's  Hasp.  Gaz.,  Lond.,  XXXII,  223,  1918. 

23.  McDonald.  J.  A.  Arch.  Neurol.  &  Psychiat.,  II,  134,  1919. 

24.  McIntosh,  J.  Report  on  Obscure  Disease,  p.  58  (see  above). 

251 


252  BIBLIOGRAPHY 

25.  MacNalty,  a.  S.  Report  on  Obscure  Disease,  pp.  12,  69  (see 

above)  Proc.  Roy.  Soc.  Med.,  Lond.,  XII,  No.  1.  Sect,  of 
Med.  pp.  i— xxiii,  1918. 

26.  Marinesco,  G.  Report  on  Obscure  Disease,  p.  48  (see  above;. 

27.  Melland,  C.  H.  Brit.  M.  J.,  Lond.,  1918,  I,  559. 

28.  MoR-\x,  V.  Brit.  J.  Ophth.,  II,  529,  1918. 

29.  MoTT,  F.  W.  Proc.  Roy.  Soc.  Med.,  Lond.,  XII,  No.  I,  Sect,  of 

Med.,  pp.  i — xxiii,  Nov.  1918. 

30.  Neal,  J.  J.  Am.  M.  Assn.,  LXXII,  714,  1919. 

31.  Netter,  a.  Bull.  Acad,  de  Med.,  Par.,  3.  s.  Vol.  LXXIX,  No. 

18,  p.  337,  May  7,  1918.  Soc.  Med.  des  Hdpitau.v  de  Paris, 
3  s.,  Vol.  XLII,  No.  11-12,  p.  307,  April  18,  1918. 

32.  Netter,  M.  Soc.  Med.  des  Hopitaux  de  Paris,  3.  s..  Vol.  XLII, 

Nos.  15-16,  p.  424,  Maj^  3,  1918. 

33.  PoTHiER,  O.  L.  J.  Am.  M.  Assn.,  Vol.  LXXI,  715,  1919. 

34.  Robinson,  C.  A.  Indianapolis  M.  J.,  XXII,  163,  1919. 

35.  Rosenow,  E.  C,  and  Towne,  Edward  B.  J.  Med.  Research, 

Bost.,  Vol.  37,  p.  175,  1917. 

36.  Sachs,  B.  N.  York  M.  J.,  Vol.  109,  894,  1919. 

37.  Sainton,  P.  Presse  Med.,  Vol.  26  (2),  486,  Sept.  23,  1918. 

38.  Strauss,  I.  &  Loewe.  L.  J.  Am.  M.  Assn.,  LXXIII,  1056, 

1919. 

39.  TiLNEY,  F.  Poliomj'elitis  with  Prolonged  Somnolence.  Neurol. 

Bull,  N.  Y.,  Vol.  1,  No.  1,  p.  7,  Jan.,  1918. 

40.  Tucker,  B.  /.  Am.  M.  Assn.,  LXXII,  1448,  1919. 

41.  Vaidya,  S.  K.  Lancet,  Lond.,  1918,  II,  322. 

42.  Vaughan,  V.  C.  West.  Virg.  M.  J.,  XIII,  454-459,  1918-19. 

43.  Von   Wiesner,    Wien.  kiln.  Wchnschr.,   Vol.  XXX,  July  26, 

1917. 

44.  Wegefarth,  p.,  and  Ayer,  J.  B.  J.  A^n.  M.  Assn.,  LXXIII, 

5-12,  1919. 

45.  WiisoN,  S.  A.  Kinnier.  Lancet,  Lond.,  Vol.  II,  No.  1,  p.  7, 

July  6,  1918. 

46.  WooLLEY,  P.  G.  J.  Lab.  &  Clin.  M.,  St.  Louis,  IV,  456,  1918, 

1919. 

47.  Zuelzer,  Influenza.  Ziemssen's  Handbuch  der  speciellen  Patho- 

logie  und  Therapie,  2,  506;  part  2,  1874. 
This  volume  also  includes  articles  on  epidemic  encephalitis 
and  on  special  cases,  by  Drs.  Frederick  Tilney,  Henry  Alsop 
Riley  and  Hubert  S.  Howe,  which  appeared  in  the  Neurological 
Bulletin,  New  York,  Vol.  II,  No.  3,  p.  106,  March,  1919,  and 
Vol.  II,  No.  5,  p.  190,  May,  1919. 

Paul  B.  Hoeber,  67-69  East  .59th  Street,  New  York. 


University  of  California 

SOUTHERN  REGIONAL  LIBRARY  FACILITY 

405  Hilgard  Avenue,  Los  Angeles,  CA  90024-1388 

Return  this  material  to  the  library 

from  which  it  was  borrowed. 


wc 


3  1158  00831  8726 


A     000  365  235     1 


I'ii'l 


i 


I   ; 


Univer 

Sou^ 

Li] 

liiiiiiiuiiiiiiiiiuuni 


